Dáil Éireann debate -
Tuesday, 29 Apr 1958

Vol. 167 No. 7

Committee on Finance. - Vote 64—Health (Resumed).

Debate resumed on the following motion:—

That a sum not exceeding £6,092,900 be granted to complete the sum necessary to defray the Charge which will come in course of payment during the year ending 31st March, 1959, for the salaries and expenses of the Office 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).

Mr. O'Sullivan

I had just opened my remarks on this Estimate on the last occasion it was discussed here and I referred to the improvement which the Minister, happily, had to report in the introduction of his Estimate— an improvement particularly in the mortality rate of T.B. I asked him then to have a quiet word with his colleague, the Minister for Lands, and to prevail on him to cease his weekly excursion into the realm of capital expenditure, decrying it and failing to advert to any of the benefits that accrue from the expenditure of moneys, particularly back over the last ten years.

There are many people in high places to-day who are very critical of government since we attained self-government. This is one realm, surely, in which we can be proud of our achievements. Surely there were few small countries so adversely affected as we were by the scourge of T.B. The erection of sanatoria, the improvement in housing and sanitary facilities and particularly in the attitude to the disease, has resulted in an improved situation to-day which is certainly gratifying. It is true, as Deputy Brennan has stated, that it is impossible to estimate in terms of pounds, shillings and pence, the good that has resulted from the initiation of an intensive drive to combat that disease. There is no record of many hundreds of wage earners who have returned to useful employment and are in the position to maintain their families in consequence of the assistance they have been given.

If to-day we have a surplus of bed accommodation in some of our sanatoria, it should not be beyond the capacity of the Department of Health to fill those beds and relieve what is still a distressing situation in many of our mental institutions. It is regrettable in a Christian country such as ours that many of the beds in our mental hospitals are occupied by people who are more or less jettisoned by their own families, but accepting the situation as it is—we had and still have conditions of overcrowding—some little relief has been afforded by the transfer of patients from those institutions to some of the hospitals formerly occupied by T.B. patients.

In regard to my own constituency, the Minister adverted to the fact that Heatherside sanatorium was one of those used for that purpose. There was a certain local reaction and some people were opposed to its use for this purpose. I want to say that those of us in public life in the constituency who were approached, immediately supported the attitude of the Department and did what we could to quell that local opposition to the hospital being utilised for that purpose.

It is with reluctance that I say just a few words regarding a matter which is causing concern in my constituency —the recent inquiry in Mallow. It would be well if the Minister could expedite the publication of a report in respect of that inquiry. In justice to the parties involved, it is very desirable that the unrest which exists should be cleared away by a report at as early a date as can be achieved.

Other Deputies have referred to the dire need for an extension of facilities for institutional treatment of mentally defective children. The Deputies who spoke were complimentary to the institutions in their own parts of the country, but I should like to stress, as other Cork Deputies have done, the wonderful work being done in that respect by the Brothers of Charity at Lota. Anybody who visits that institution and sees the wonderful work being done by the brothers will realise that they are contributing in a very great way towards relieving a situation which is acute in this country. There are many mentally defective children, who are denied in their homes or in the vicinity of their homes that personal attention and that trained attention which could help them to overcome their afflictions, and if these communities have succeeded in many instances in restoring these children to the point where they are able to play a full part in adult life, I think any assistance we can possibly give should be given without stint.

I do not know whether any progress has been made regarding the request which I understand these Brothers made some time ago for recognition as teachers by the Department of Education. I think it is a just claim and it would assist them considerably if recognition could be given. After all, what is their work if not a work of education and an extremely difficult educative task?

I should like to refer to one other matter, that is, the disease which we experienced in Cork some time ago, poliomyelitis. When civil servants are affected by tuberculosis an opportunity is given to them of hospitalisation and recuperation and return to the Service. I would ask the Minister to examine the possibility of extending similar facilities to civil servants affected by polio. I know of a few cases in which it was extremely unfortunate that they were not in the same category as victims of tuberculosis and that it was not possible for them to get the same facilities. I know that the point of difference made is that in one case the encouragement for hospitalisation must be given and that, in the other, hospitalisation is a "must". In justice to the people who have been affected by polio—God forbid that we should have further instances arising—such victims should receive the same facilities as those affected by tuberculosis.

In the financial commitments of this Estimate, we have, as in other Estimates, a reflection of the consequences of the withdrawal of food subsidies last year. Every public institution is affected: some of the cost has to be borne by rates and it is not inconsiderable, but in this Estimate we are again voting some moneys for a charge which arises directly from the Government's action in withdrawing the subsidies.

I conclude by making an appeal to the Minister to launch a drive for the consumption of more liquid milk. The Government and the country are faced with the problem of disposing of our surplus milk. We have not made the effort other countries have made to make people milk conscious, to get them to regard it as an asset, a good food. Surely the Government would be recouped some of the expense they have to meet in the hospitalisation of children and the incidence of disease, if they encouraged people, by a publicity drive or any other means, to consume more liquid milk. Would it not be more practicable than having to pay farmers to consume good fresh, Irish produce? It would give a return in a reduction in the incidence of disease.

There are many other essential foodstuffs that are to-day in reduced consumption—creamery butter is one that I may instance—in consequence of the Government's actions in placing these good foods beyond the capacity of very many families to purchase. No doubt in consequence of that we shall have reflected in our Health Estimates for some years to come the fact that people with limited incomes cannot now afford to provide themselves and their families, particularly in the case of young families, with good fresh food which will ensure they will not be susceptible to the many diseases which affect people whose nutritional standard is not sufficient to withstand the impact of these diseases.

We all unite in saying that the report of the Minister is one we can all feel happy about in regard to the improvement effected in our health services. It reflects the wisdom of those who decided that this aspect of health should get a certain priority and that nothing should be spared to ensure that those who are affected by disease should receive attention as quickly as possible and that everything should be provided to make it possible for them to return to their employment and their normal way of life in the shortest possible time.

Mr. Healy

Due to the building of regional hospitals and sanatoria throughout the country over the past ten years, it is possible that some small institutions will become available now for other purposes. It is the duty of every Deputy to inform the Minister as to the most necessary purpose to which those institutions could be put. Few will differ from me when I say there is tremendous necessity for provision for old people—old people's homes, homes for chronics and homes for convalescents. If I deal with that subject first, it is because I am on the board of an institution where, because alternative accommodation was made available, 180 old ladies could be certified as sane and sent down to Heatherside. That proves to me conclusively that they should never have been in the mental home in which they were left previously. I am informed also that, if provision were made available in the morning, we could discharge from that home as perfectly sane and entitled to all the amenities of normal citizens at least 200 old men. It is a terrible reflection on our way of life that old people have to be certified as insane and condemned to spend the last days of their lives in mental institutions.

I was rather critical of this some years ago, because I felt it was a reflection on the younger generation, who did not take proper care of their old folk. However, that is not a complete answer, since very often, due to overcrowded conditions, parents with seven, eight or nine children, up to lately have been living in one or two rooms and there was very little place in the home for an old person. Conditions may be somewhat different in rural areas, but they have their own problems. There is certainly a bounden duty on us now to provide homes for the old people.

Then we have the case of chronics, who are taking up beds in hospitals— voluntary hospitals and accident hospitals—which were never intended to house people of that category. We demand in different centres of the country new hospitals, while the fact is that if we could get rid of half a dozen chronics in our local hospital, we would have enough beds. We could provide for 100 in Cork City if the existing hospitals got rid of the chronics who have been there for up to three or four years. Now, 100 beds is a new hospital. Provision should be made to deal with this problem.

There is also in our area tremendous need for convalescence provision. Persons need stay only for a week, ten days or a fortnight in hospital after an operation, and if they could be moved to a convalescent home, the bed would be available again for persons in need of an operation or medical attention. As it is, a person has to stay twice or three times as long, or even longer, than he should be there. I am making these suggestions because I feel that many of the institutions which become available— smaller institutions which have been doing good work in other spheres up to now—may be suitable for some of the people about whom I speak.

There is need also in my part of the country for a children's hospital or wards for children. That is the other end of the line—if you look after the children and if they can be cured and put on a healthy basis at the beginning, it certainly will mean a brighter future.

I want to join, as we all do, with Deputy O'Sullivan in paying tribute to the Brothers at Lota. I am sure the Minister and the Department will be very sympathetic in giving them whatever facilities they require for educational purposes. These men, as many of us know, have a great vocation, a vocation given to very few. They should be, and I am sure will be, helped by the Minister and the Department, no matter what Party is in office.

There is one point about the Health Act which I should bring to the Minister's attention. It is the peculiar position of a person who has a family doctor who is not attached to a hospital—in other words, he has not got beds in a hospital where there is a public ward. It means that that doctor has to surrender his patient, if the patient is to get the full benefits under the Health Act. I wonder if the Minister would address himself to that problem and see if there is any way of overcoming it. I do not think a medical man should be compelled to surrender his patient completely. If a doctor has not got beds in a hospital or there are only private wards or semi-private wards, there is no option but to send the patient there, and in that way the patient would not derive the full benefit of the Health Act.

Dr. Browne

As there have been very few changes of policy, as far as I can see, in the Department of Health in the last year, I am not going to deal with it as fully as I did last year. There are a few points, and one in particular, with which I should like to deal. I should like to find out whether the Minister's policy is irrevocably fixed in relation to poliomyelitis.

Before dealing with that, I should like to deal briefly with the question of cancer. I think the findings here are the findings of most other countries, that the cancer rate has gone up, the incidence of cancer has gone up. I think the Minister's explanation is to a considerable extent true—better notifications, more accurate notifications and better facilities for diagnosis. At the same time, the essence of the treatment of cancer is the earliness of the diagnosis. Because of that, it seems to me that rather more could be done in the question of the education of the public about this really terrible disease.

There are two main considerations which a patient has to consider when faced with the possibility of having cancer. One of them is the instinctive fear that we all have, of knowing that we have what is likely to be a fatal disease. That leads to our hesitation in going to the doctor in order to be told about it. It leads unfortunately to the position where the patient tends to go to the doctor, in a very high percentage of cases, when the case is too far gone.

At the same time, I think there is another factor. Our health services are so organised that a very high percentage of our people do not have ready access to medical diagnosis or treatment facilities. Because of that, an unnecessarily high percentage of our people suffer from cancer and continue to suffer unnecessarily and unduly long. In the first place, they are frightened of the cancer itself and in the second place, they are frightened of the doctor's bills and the hospital bills, which the average unfortunate family man in the middle income group has to face—the white-collar worker in particular.

The terror of cancer—and it is a terror in most cases—is bad enough in itself, with all its implications to the father and mother in a family; but when, on top of that, there is fear of the considerable expense involved, the possibility that the money may be unnecessarily laid out, as it may be a false alarm, it means that a very high percentage of our people do not go to the doctor sufficiently early, when they have cancer, and consequently when they go, the case has so advanced that there is very little that surgeons or physicians can do for them.

There is the question of lung cancer on which I asked the Minister many questions during the year. It is now established, and it has been accepted by most reputable authorities, that there is a definite link between heavy cigarette smoking and cancer of the lung. One of the tragedies of this problem of cancer of the lung is that, even when found early, it seems to be a very slow and difficult thing to cure. However, I would ask the Minister to reconsider his attitude to the propaganda and educational side of the cancer question.

I can quite see that the Minister appreciates the danger of inducing a cancer phobia in people, frightening them out of their lives about a disease which they know to be in so many cases a fatal disease and in that way inducing a kind of hysteria, which would be unhealthy and undesirable. At the same time, I believe it is possible to initiate an intelligent and balanced type of propaganda or educational scheme through the usual media of the radio, the newspapers, and so on, in order to try to give people some idea of the early signs that have to be watched for in the more common and more curable kinds of cancer. If that were done, more people would go to their doctors early and more cases would become amenable to treatment.

As regards the connection between lung cancer and smoking, it is a very difficult problem for a Government because of the serious financial implications in relation to revenue, and so on. The case made by the tobacco companies is that there are other factors and consequently there does persist a certain element of doubt, the attitude that you can smoke 100 or 50 cigarettes a day and die in your bed of pneumonia or some other disease and not get cancer of the lung. I can see, therefore, that there is a case for not being completely ruthless about refusing to permit the smoking habit, even if that were possible. Nevertheless the propaganda on the other side is allowed to be unnecessarily provocative. They are able to use all the media of propaganda, particularly the newspapers, the cinemas and the radio, if they wish to. The case for the other side is being persistently put in a very insidious, clever and convincing way. The Minister has said he has attempted to meet the situation in the schools through leaflets, and so on, but we should have something to counterbalance the pernicious propaganda in relation to cigarette smoking which we do know in a percentage of cases leads to this truly terrifying disease, as anyone who has had any experience of it knows it to be, cancer of the lung.

It might be said—I think the Minister did say it to me on one occasion— that the public are well aware of the case against cigarette smoking and consequently they should take action themselves. On the other hand, the Government does step in on occasions where it believes it is in the public interest to do so. We need only mention the Dangerous Drugs Act. The people know about opium smoking, morphia taking, cocaine, heroin, and all the other forms of drug addiction and obviously the fact that they know about these things is not considered sufficient to prevent these addicts from continuing to take them. Consequently, we have the Dangerous Drugs Act to prevent the use of these drugs, except on a doctor's prescription. I am not suggesting that tobacco smoking should be abolished altogether, but some curb should be put on the widespread mollifying and reassuring propaganda of the tobacco companies, or at least the people should have the other side of the story presented to them so that the intelligent ones could judge for themselves.

One of the Donegal Deputies pleaded that the medical profession could not make up its mind and state categorically that the nicotine drug is a dangerous one. Of course, he could cite many such doctors who will not forbid him to smoke because of the dangers of cancer. One of the reasons for that is that many members of my profession are themselves cigarette smokers and consequently are addicts. They, therefore, find it very difficult to take a strong line on the question of the prevention of cigarette smoking. However, the case does exist for reconsideration by the Minister of his attitude in relation to the permission of continuous advertisements or for more dynamic and positive propaganda by the Minister's Department in order to let people know as much about the case again cigarette smoking as the tobacco companies have so cleverly made them see the case for their side.

Everybody is pleased with the improvement in the figures in relation to infectious diseases and that has been the result of intelligent work over a number of years by the Department of Health, irrespective of the Ministers in the Department. At the same time, I would ask the Minister if he would reconsider his apparent present policy in relation to this scourge which appears to be a relatively recent visitor to Ireland to any serious extent, namely, poliomyelitis.

From the success achieved over the past 20 years, and more, in relation to such infectious and contagious diseases as typhus, typhoid, and diphtheria we have all learned a great deal. We know that these diseases are now preventable; we know that they are curable. The steps taken to curb these diseases by means of immunisation, vaccination and inoculation have paid remarkable dividends in lives saved and suffering avoided. A certain pattern of behaviour from a medical hygiene point of view has paid enormous dividends.

Recently I read an article by that very eminent biologist, Dr. Meenan, in which he said that the type of poliomyelitis we tend to get here is a particularly virulent form. He recommended widespread vaccination. There have been remarkable advances in medical science over the past ten years, from prontosils to penicillin, with the result that the discovery of a vaccine likely to reduce the occurrence of an infectious, disabling, crippling and killing disease may go comparatively unnoticed. The successes achieved in other fields of scientific medicine over the past ten years tend to over-shadow the discovery of yet one more vaccine. But it has been accepted by the medical profession generally that this impending control —and that is what it will be—of poliomyelitis will mark one of the most forward steps in preventive medicine. That is the opinion of experts. I am not an expert in this disease.

The reaction of most civilised societies to this vaccine has been to make it as widely available as possible to children, young adults and pregnant mothers. The Minister appears to have changed what was heretofore a consistent line of policy in the Department of Health. In the fight against tuberculosis, B.C.G. inoculation is made available free to all sections of the community. Vaccination against smallpox is free and available to all sections of the community. Indeed, smallpox has been completely eliminated. Diphtheria inocuation is available free to all sections of the community.

There is now a departure from that consistent line of policy, an enlightened and intelligent policy, over the years as has been proved by results. I consider that departure to be a most retrograde step; I consider it most undesirable. It shows a cynical disregard of our responsibilities to the children of this nation. I understand that this vaccine is to be made available to children in the lower income groups over the age of six months and under the age of ten years. It will not be available, free, to the children in the other income groups. The parents in the white-collar worker group and those in analogous positions, who find it hard enough to make ends meet as things are, will now have to shoulder the hideous responsibility of trying to find the money to protect their children from a preventable disease, a disease which can kill children, with a most horrible death—a suffocating, strangling, terrible death.

I have seen children die from this disease; I have seen children die with paralysis of the respiratory muscles, children choking to death—in fact, drowning to death; and this is the type of death to which we are deliberately exposing thousands upon thousands of our children. Should they survive that death, we are condemning them to being crippled, maimed or deformed for the rest of their lives. That is an extraordinary decision coming from a Minister who is a member of that Party which has such a magnificent record in regard to health legislation, in its consideration of the aged, the under-privileged and the sick. This was the Party that, so far as I know, had so much to do with the magnificent 1947 Health Act.

There are many arguments that can be advanced, I suppose, on both sides. I and others believe that all health services should be free and that there should be no means test. Others still hold that people should be made to pay for services rendered. One of us may be right; one of us must be right; but, while we are resolving these differences, the people who will suffer because of our continuous disagreement are the children who will not be vaccinated against poliomyelitis because their parents cannot afford to protect them.

There was a collection recently in this city and boxes were carried around by children on crutches and with irons on their legs, begging for pennies to Help Fight Polio. These were the victims of the past. The results could not have been prevented. Remember, there need be no more crippled children as a result of this disease, provided we are prepared to find the money to make this magnificent vaccine available free to all sections irrespective of income.

I know a man with a family of 12 children—what would be called a good, Catholic, Christian family. He is a white-collar worker in the middle income group. It is quite clear that that man simply cannot afford to have those 12 children vaccinated. Three vaccinations cost a guinea, possibly less; but a guinea can be expected. It is quite complicated. There are certain rather strict regulations in the handling of the drug which the doctor has to observe, and presumably he must ask what he considers to be a reasonable fee. I am not criticising him at all. It is quite clear that that man cannot afford vaccination for his 12 children. What is he to do: vaccinate six and let the other six take their chance? And then visit them in the fever hospital when they are struggling for their lives because the State has decided to save money at their expense?

Mr. Dillon

Would the Deputy mind my asking a question? Is polio vaccination not free within the limits of the availability of supplies of vaccine ?

Dr. Browne

No, Sir. According to the Minister, we have unlimited supplies; but vaccination is confined to children of the lower income group over six months and under ten years.

Mr. Dillon

There are unlimited supplies of vaccine?

Dr. Browne

As far as I am aware. The Minister may correct me, if I am wrong.

Mr. MacEntee

We understand it will be freely available, but the Deputy is no doubt not unaware of the position in Great Britain where it has not been as freely available as they thought.

Dr. Browne

I am making the case, assuming it is freely available, that it is a very serious thing indeed. No matter what our differences are about whether it will be free or not, it is the children who will suffer. It is the unfortunate parents who will have this terrible decision this spring or summer. I know that 12 children is an excessively large family, but the average family of four to six children will be faced with the same problem. They have to pay the doctor. The doctor has a right to be paid a reasonable fee for his very skilled services in this regard.

What do they do without in order to vaccinate the children? Again, it means a tremendous amount of understanding because the child will not inevitably get polio. The Minister's figures show that last year there were 147 cases and 13 deaths; but there was an epidemic in 1956 in which there were 499 cases and 20 deaths. None of us knows which of our children is to be marked down for that disease and which of us can afford to take a chance of not vaccinating the child? It imposes on him—and, as I say, largely on the unfortunate white-collar worker who has life very hard, as things go—this very difficult dilemma of where he should find the money—take it away from school fees, take it away from going for a holiday, cutting down on food or whatever it may be—in order to vaccinate against a disease which the child may not get. But if the child does get it, clearly there are many parents who will regret for as long as they live the sight of their crippled children struggling around the house with these irons and crutches and all the rest of the horrible paraphernalia associated with this terrible disease.

It is something which should not be permitted to happen. I must say this with all sense of responsibility. If the Minister intends this to go on, if he intends to permit this state of affairs, if he does not intend to make this vaccination freely available to all who wish to use it, then if there is an epidemic and if there are 400, 500 or 600 children or more—there could be more because this disease is increasing here in Ireland—if some of them, 30, 40 or 50, die from a preventable disease in 1958 and if there are 400, 500, 600 or 1,000 young cripples hobbling around this country as a result of being permitted to suffer from a disease from which they could readily and easily in most cases have been safe, then I must lay the responsibility for that condition with the Minister. The Minister must be held entirely responsible for that situation, should it happen.

We have been told that in the scale of values, when these things were being weighed up, the money position was an important consideration. I understand the money position is the important consideration. Are we justified in saving money at the expense of these children? An extraordinarily curious sense of values seems to have motivated those men who brought in a Book of Estimates which increased money for the National Gallery, the Royal Irish Academy, the School of Advanced Studies and various relatively unimportant institutions in the State, such as the absurd and pretentious Presidential Establishment, the unnecessarily large size of our Defence Forces—surely any or all of these could be pruned in order to provide the money to prevent a horrible, crippling, avoidable, painful, mortal, preventable disease?

I cannot understand the callous cynicism of men who could come to a decision such as that, and at the expense of the weakest section in any society—the children of a nation who are so dependent on us for their protection against these catastrophies. I only hope that the Minister will be able to give the matter some little more consideration, and that, assuming that the drug becomes widely and readily available, he will allow it to be disseminated freely, together with a widespread, intensive and dynamic campaign on the radio and in the Press in order to assure the public that the drug is within the ordinary risks of medicine, that it is free from danger and that it does confer a high level of immunity on the children and that, because of that, it is well worth getting their children vaccinated.

That would seem to me, even if one leaves aside the humanitarian aspect of a disease which is only beginning to intensify itself in this country, the wisest thing to do and, looking at it from the gombeen mentality, the cheapest thing to do, if it would save these children's lives and save them from preventable suffering, pain, hardship and risk of disease.

I have only a few comments to make on the general question of the health services, I have discussed them at great length before and do not propose to discuss them again. The Minister made one remark about the voluntary health insurance scheme. He dismissed it with the phrase: "Conditions have proved attractive". I do not think that the conditions of the voluntary health insurance scheme are attractive. I shall not deal with them in any detail. There are 460,000 persons who, it is alleged, should be covered by this scheme. In reply to a question, I was told that 45,000 applied and 28,000 applicants are in fact covered by the scheme. That makes 28,000 out of 460,000. I do not know if that figure has been increased by now, but that is the figure I got when I asked the question recently in the Dáil. Even if the 45,000 do contract into the scheme, it leaves 400,000 persons who do not find the scheme attractive. I know it will be said that it is early days and that we should give the scheme time. That may be so. The essence of a good health scheme is that it be availed of from the outset by the average family. The average conscientious parent does not want to delay providing cover for his family, if he can afford to do it, and I do not think the average man can afford to do it having regard to the very limited provisions of the voluntary health insurance scheme.

There was some talk of a comparison as between what they give and what the State can give, even in a society where we object to State health services. I was interested in one figure given by the Minister about the cost per head of the population of health services. It works out at £5 10s. per head. I do not agree that the level of the service is as high as it should be, but, for what it is worth, we provide a health service of a kind for, I understand, anything between 600,000 and 800,000 persons—a dispensary service, a hospital surgical service, certain medicines and appliances, a dental service, of a kind, admittedly, but some form of dental service, a general practitioner service and a maternity service as well as care of the eyes, an ear, throat and nose service—in fact. a reasonably comprehensive service for between 600,000 and 800,000 persons. The two different figures were given, so I am not certain which is the correct figure, but that service is provided for between 600,000 and 800,000 persons in the lower income group.

This fairly comprehensive cover for this group is provided by the State at a cost of £5 10s. per head of population and, if I am right, in addition to this, all of us are covered in relation to infectious diseases, fevers, typhoid, diphtheria, measles, scarlet, polio and diagnostic services in respect of all these diseases, treatment facilities of a very complicated and expensive kind in relation to all these diseases and, as I have said a moment ago, vaccination services for these diseases, with the exception of poliomyelitis. I have not mentioned all the benefits that come from that public health service. Presumably, there come out of that the dispensary services and the various facilities under the sanitary services. All these are covered at a cost of £5 10s. per head of the population.

I know the figures are not absolutely comparable but, in view of the great criticism that there is of State control of health services and the incompetence of State control of health services and the wastefulness of these things, and so on, it is interesting to consider broadly these two points: £5 10s. per head of the population covers about 700,000 or 800,000 people, with a dispensary service, surgical, county hospital, medical officer of health, tuberculosis, fever and such services. The voluntary health insurance, on the other hand, offers to the people for three different scales, one at £13, one at £17 and the other at £23 odd, a service which does not include a maternity service, which does not include a general practitioner service and which adds a load of 15 per cent. after the age of 65, when you need a health service most, which does not insure you at all after the age of 70, in the few years before you are going to die when you will certainly get sick. It does not provide, as far as I am aware, appliances, spectacles, teeth, hearing aids and so on. You have got to make certain that you do not get sick in the first 13 weeks of your admission and, when you get well in hospital, you go home or back to work because there is no provision for convalescence.

It is clear that the voluntary health insurance is a specialists' field. They have had a wonderful time out of it. The Minister for Health knows the needs of our people. I do not think it is right to dismiss the great, real, demanding needs of this big section, 400,000 or 500,000 at least, of our people, who are not classified under the voluntary health insurance scheme and, even if they were, would not be fully or properly covered in respect of maternity, the greatest medical need of any family, and in respect of the general practitioner care from which flows all the early diagnosis, the necessity for early diagnosis, which leads to the early cure of all our diseases, particularly cancer, about which I was talking previously. Therefore, there will only be a tiny percentage of these people in the country. I believe it will not be a question of continuing accretions to this scheme. I think it will settle down at a figure of about 80,000 to 100,000 at the very most, and there will still be 300,000 or 400,000 people not covered by this scheme at all. As I say, even if they were covered it is only a very limited cover indeed, and is no substitute.

Let nobody fool himself on either side of the House, this voluntary health insurance scheme is no substitute. It is a mere sop to those who want to be able to say: "Yes, we are concerned about you in your ill-health." That is the middle income group who are probably the most hard pressed when it comes to paying doctors' and hospital bills these days. As the voluntary health insurance booklet says:

"Under present circumstances it has become increasingly difficult for the single person and almost impossible for the head of the family to provide, out of income or savings, for the many unforeseen expenses which will have to be incurred in every case of serious illness or accident."

That section of the public simply have not got the money. They have not got £13, £17 or £20 to put into that additional health service every year. It is a selective form of taxation, and should be imposed over the whole population so that all of us share in the burden of trying to provide an equitable health service for all our people.

We know quite well the correct basic fundamental principles for our health services. We have seen them work in tuberculosis and fever hospitals. We have seen them work in the Six Counties and in Great Britain. The criticism of the national health service there is all gone now. It is probably the finest health service in the world, this service which was so heartily derided in newspaper headlines in its early days. It is a thing of which any man should be proud—to be a member of a society that did so well for its under-privileged and its sick. I am quite satisfied that ultimately we shall have a society in which we shall accept our full responsibilities in this very important question of taking care of sick people. We will end the unbelievable anomalies of our existing health services.

There are now apparently five different grades of health services. Three of them are in the voluntary health scheme, the fourth is the dispensary health service and then there is the free-for-all. How they get by, I do not know. There is great dissatisfaction with the health services and it all stems from the existence of the means test. Even where people are justifiably excluded from the health services they have a sense of grievance. There are the border-line cases.

An Ceann Comhairle

I do not like interrupting the Deputy, but is he not going back on a fundamental point embodied in legislation?

Dr. Browne

I was told that the voluntary health scheme was serving a particular purpose in the health service which it does not do, but, however, I shall not pursue the matter further beyond saying that we have got to face the fact, that one way or another, by taxation or by increasing the national income, we must be able to provide the wealth which is needed to expand our health services. In the general medical services at the moment the question of the blue card is causing great dissatisfaction amongst the people. I know the Minister will ask: "How can you prove that—an Independent Deputy in his own constituency?" To the extent that I do keep very close to the people in this regard in my own constituency, I can say there is great dissatisfaction concerning the application of the health services generally. A proper solution will only come when we accept the principle that the means test be abolished altogether.

I believe that one of the most important factors in having this means test ultimately abolished—I am quite certain it will be abolished in time— stems from the fact that our people are now getting a very intensive and bitter education on the meaning of a means test, of which they were never completely aware before. They are now finding the true meaning of the slogan once used by the Medical Association, who are so pleased with themselves now: "The doctor-patient relationship." In many cases, particularly the higher they go, particularly in the specialist and hospital side of the service, it depends entirely on the amount of money which the patient happens to have.

An Ceann Comhairle

Could the Minister abolish the means test by an administrative act?

Dr. Browne

Yes, Sir.

An Ceann Comhairle

I do not think he could.

Dr. Browne

I will conclude by saying that there is this dissatisfaction. The Minister will get the full support of the public in abolishing the means test, as a result of the education which they have received in the last few years. If he does that, he will be able properly to be proud of the whole gamut of health services, as he is to-day of the free services which he was able to pronounce were such signal and outstanding successes.

Mr. Loughman

I wish to refer to some remarks made by Deputy Carty which I believe might mislead the public generally, and which might have a bad effect so far as the confidence of the people in public hospitals is concerned. Among the statements he made was one in which he said that, in a hospital which he knew, patients in the public ward were given to believe that better treatment was given in private wards.

He also made the suggestion that the drugs supplied by a very well-known and, in my opinion, efficient drug company in this State to our public institutions were of poor quality and even that they would not be stocked by ordinary pharmacists in this country. That also was a very damaging statement. He mentioned particular drugs and said that samples of them had been sent back. I do not see anything wrong with that because if the samples were taken at the source and returned as not of good quality that was just a simple matter of checking and this drug which was of bad quality did not reach the patients.

For many years I happened to act as compounder of medicines at a very big hospital in this country. I would say at the outset that from my experience the poorest person in my town would have available to him or her in that hospital the best drug possible for the disease he or she suffered from that is procurable in this country to-day. I would say that the poor person is able to get a drug which even the very rich sometimes would find it difficult to pay for continuously.

I should also like to suggest that in my experience of the health authority who is the county manager, when the medical officer decides that a particular drug or appliance is necessary for the relief or cure of a patient he never questions the doctor's order. No matter what its cost or how difficult it might be to get supplies of that drug or appliance, he, at any rate, put no obstacle in the way and the drug or appliance was always made available to the patient.

In my experience, I have never seen any discrimination between those in the public ward and those in the private ward. I am very happy to say that one thing of which we may very well be proud in this country is the hospital service we have for our people and particularly for our poor people who need that service most.

As far as the quality of the drugs is concerned, I have been supplying 200 or 300 phials of that drug in this hospital every month over a great number of years. I have never had one solitary complaint concerning it. It is very damaging that such a statement should be made by a person who, perhaps, was not clear in regard to what he was saying. As well as streptomycin, which he mentioned, he named other drugs also. That could have a very damaging effect on the firm that was the supplier. His statement would pin-point that firm which is giving not only excellent employment but which, also, is in the form of a pioneer in a fine chemical industry in this country. So far from being discouraged, they should have from our people every encouragement so that we might develop the industry to an even greater extent.

I should like to support the plea made by Deputy T.F. O'Higgins, the former Minister for Health, for an examination of the dispensary service in this country and, if possible, to have an experiment with a new system. He told us he felt that, since we had established the choice of doctor in the case of the mother and child service, we might easily expand it to the dispensary patient. In my opinion we have reached the stage when something of that nature must be done.

I know that the doctors throughout the country give good and efficient service. I know that there exists between them and their patients the relationship about which Deputy Dr. Browne spoke. At the same time, it is a fact that many dispensary patients are compelled to go to a doctor when they would much prefer and have greater confidence in some other doctor. A doctor might be even a personal enemy of the particular patient and because of the fact that he must go to that particular doctor, very often he is compelled to go to some other one and pay a fee. However, apart from all these considerations, I think the old system of confining the patient to a particular doctor is outdated and that in the provision of a medical service for a member of that particular class, we should give him or her at least the service which is available in the mother and child service, namely, the choice of doctor.

I should like to point out that, while hospitalisation has advanced to an enormous extent, our dispensary service has not advanced at anything like the same rate—at least that is my experience and opinion. I have been attending at dispensaries since 1915 in the position of a compounder of medicine and I have some idea of the advances that have been made both in the hospital and in the dispensary. My remarks to the effect that the hospitals have out-distanced the dispensaries are perfectly true.

I think it is bad at the present time that 30 or 40 persons who are sick, or some of whom may have come on behalf of sick persons, must sit very often in buildings that are not suitable and wait their turn for a doctor who has more than he can do to give them proper service. Then, if they have to get medicines, they must, in many cases, go to another department where they will have to wait another ten or 15 minutes to be supplied. I understand that these people think there is a great difference between the medicines they get at the dispensaries and the medicines people get at pharmacies throughout the country. I think that, very often, there is some truth in that. It is something which should not happen.

Once again, let me say that in the dispensaries we may procure any medicine for patients that is available. The Minister, the Department and the public health authority in the county will not deprive us or any doctor of that right. At the same time, I do not think that service is available generally. I believe that if, as well as giving the patient a choice of doctor, they also gave to the patient the choice of pharmacist, they could safely abolish the dispensary as it exists at present without the State's incurring any grievous loss. I believe that if the cost of the compounder, the cost of the place in which he does his compounding, the heating and maintenance of that place, and so on, were deducted from the total cost of the dispensaries, it would be found that a very considerable profit would be available which would make it worth the while of the chemist to undertake that work.

I advocate strongly that the Minister have that position examined and at least try to see if he cannot have a trial scheme such as that which Deputy T.F. O'Higgins suggested in some of the cases in which permanent appointments are being made to medical posts at the present time. We have now reached the stage when a choice of doctor is essential. I believe the people are entitled to it. I would strongly recommend to the Minister that he should give that suggestion every consideration.

I should like to join with those who made appeals to the Minister to try to do something for mentally defective children and for those who suffer because they are deaf and dumb and for whom it is practically impossible to get space in any of the various homes in this country. I am sure every Deputy can give numerous cases of that description. One woman who called on me quite recently has five children, one of whom is mentally wrong and and actual danger to the other four. She spends practically all her time watching that child, to see that she does not do damage to the other four children. That is a shocking position. For two years, she has been looking for some home for the child and, as far as I can see, there is no possible chance in the foreseeable future of the child being placed anywhere.

Then there is the case of a lad who is deaf and dumb. He is quite healthy and strong, but cannot be taught by his parents to do anything for himself. We understand that there are homes for such children where training will make them useful citizens, or at least help them to live their lives with greater ease. I would appeal to the Minister to examine the position, to see if it would not be possible to make more space available for such children.

There are many other aspects of the health situation about which we could talk, but they are of the kind in respect of which it would be better to deal with officials—they are all small points where experience shows to me they would help to improve the service. I will not deal with them here, but I would urge the Minister to give attention to the points I have made, as I believe they would lead to an improvement in the health position within the country.

Mr. Russell

First of all, I should like to join with other Deputies in expressing appreciation of the work of the Department of Health, particularly over the past ten years, since the passing of the 1947 Act, which has resulted in such a satisfactory improvement in the general health position in the country. If the position is not as satisfactory as we should all like it to be, we must have regard to the ability of the community to bear a completely comprehensive national health scheme. The question of cost is important and it would be foolish to disregard it in expressing wishes that everything we would hope to be able to provide for all our citizens, irrespective of whether they are rich or poor, could be provided in our present circumstances.

In introducing his Estimate, the Minister asked a very pertinent question, when he asked if value was being received for the expenditure involved. He went on to say:—

"It is difficult to give a completely satisfactory answer to the question as to whether value is being received for the money spent. It is difficult because, in the nature of things, it is impossible to measure the amelioration of sickness and ill-health, the value of human lives prolonged, and the consequent relief and happiness experienced by individuals and their families in terms of pounds, shillings and pence."

Every Deputy will support this statement. Nevertheless, we must remember that ours is a small community of fewer than 3,000,000, largely agricultural, whose national income is in the region of £160 per year per head—certainly one of the lowest in Europe and possibly one of the lowest in the world. In speaking about what we are spending on health services, we must have regard to the necessity to spend in other lines also, to expand the national income so as to provide our people with better social services, of which health is one of the most important.

I know the Minister for Lands has been criticised because, in several recent speeches, he has advocated a transfer of moneys from what we might call "non-productive outlays" to productive outlays, his argument being that, if a greater share of the national income had been spent on productive outlays during the past 25 to 30 years, this country to-day would have a far greater national income, that taxation would therefore be less per head of the population and that we would be able to afford the type of social welfare amenities which every Deputy would like to see made available to each and every citizen, particularly to those who, through no fault of their own, are unable to provide for themselves.

I gather from the Minister's speech that he is following the precedents set by his predecessors in trying to arrange that priority will be given to certain sections. Priority should be given—I do not mean that the priorities should be necessarily in this order, but I just take it as a group—to expectant mothers. I agree with Deputy Dr. Browne that much still remains to be done in that respect. We have done a lot to ensure that expectant mothers will have the necessary pre-natal treatment that they need and proper treatment during the confinement, with post-natal treatment and then treatment of the infant who is one of our future citizens, someone on whom those of us who have families may rely to provide for us and look after us in the future.

Then we have care of the old and the infirm. Those categories have first charge on any Estimate which seeks to cater for the health of the community. Thereafter, I agree with the present concentration on infectious diseases, where not alone may persons injure themselves but may injure their neighbours or other members of the community. For that reason, we have over the years expended very substantial sums of money in the treatment, in the first instance, naturally, of tuberculosis and other infectious diseases, fevers and so on. I agree with Deputy Dr. Browne that in that category the care of persons suffering from poliomyelitis should be included. I do not know what the cost would be —the Minister is in a better position to say than I am—but, accepting that principle, I think polio should be included in that category.

Again, we have to concentrate on certain specific diseases or ailments which are among the higher killers in the community. Cancer has been mentioned and I propose to say something on that later on. Cancer, heart ailments, rheumatism and mental diseases are the sort of things which should be concentrated on as specific diseases or ailments which take a heavy toll of human life, particularly in our small community.

I think I am correct in saying that the Minister mentioned also that we had come to the end of an era, the end of a decade, in the provision of health services for the community and that we had arrived at a time of pause, when we were more or less consolidating what we had done and awaiting for the national income to expand before another step forward could be taken. Any reasonable person would accept that as a reasonable thing to do.

I should have liked the Minister to have given us some idea of what we as a community had spent over that decade and, if possible, what we had spent fighting against various diseases such as tuberculosis. If my rough and ready estimate is correct, the war against tuberculosis has, over the past ten years, cost this community something between £35,000,000 and £40,000,000. When I say that, I naturally include the amount of money spent from the Hospital Sweep funds on the provision of sanatoria and which, strictly speaking, is not a charge on the community. It is the money of thousands of people who subscribe to those funds and it has been a god-send to successive Ministers for the provision of sanatoria and so on.

The Minister, in his Estimate, has dealt at some length with the question of cancer. I am in agreement with most of his remarks, but I should like to take this opportunity of expanding on this subject with which I have had some connection over the past seven or eight years. It is quite true, as the Minister pointed out, that there is a substantial apparent increase in the number of deaths from cancer over the past ten years, from just over 4,000 in 1947 to 4,817 last year, or, in other words, the percentage of deaths is now one-seventh compared with one-eleventh ten years ago. The Minister rightly pointed out that in assessing the significance of these figures, certain qualifications must be borne in mind. Facilities for the diagnosis of cancer have been expanded enormously and the treatment of cancer is now at a much higher and more efficient stage than ten years ago. There are considerably more beds available, more expert personnel available and generally speaking, the services are now considerably better, more efficient and more expanded than they were when the 1947 figures were taken.

There is the further fact referred to by the Minister that there is now more accurate certification of deaths, and that has also affected the figures. Further, the average age of the population has been going up and will continue to go up and, as it does, the incidence of cancer is bound to rise with it. It has been estimated by experts in the field of cancer research and treatment that about 2,000 per 1,000,000 people of the population get cancer, and if we accept this figure as applicable to our own small State, it would appear that somewhere between 5,500 or 6,000 people per year will become infected with cancer.

I should like to give some figures of what has been accomplished during the past ten years. As most members of the House are aware, the diagnosis and treatment of cancer up to a few years ago was carried on by two old-established cancer hospitals and I should like to take this opportunity to pay tribute to the magnificent work which these two voluntary institutions carried out for many years, despite a shortage of funds, personnel and equipment. Some seven or eight years ago, an organisation was set up by the then Minister, Deputy Dr. Browne—the Cancer Association of Ireland—and its first task was to make good the shortage of personnel, equipment and beds which existed at that time.

It may not be generally known that in as short a period as seven years ago about 2,000 people a year died of cancer because they could not get treatment, as it was not available. That position has been changed completely and we have now reached the position where we have, in Dublin, a main cancer centre and the two voluntary hospitals to which I referred. There are diagnostic centres throughout the country, in Limerick, Galway, Sligo, Tralee, Waterford and Cork, and they can cater for any number of patients coming forward and presenting themselves for treatment, so that we are now in the position that anyone requiring treatment for cancer can get it without any delay.

As Deputy Dr. Browne pointed out, it is now largely a question of getting the people to utilise the facilities which are there. Deputy Dr. Browne appealed to the Minister to inaugurate a propaganda campaign and I would suggest to the Minister that that campaign might be better-and certainly it would cost less-carried out by the institutions which have shown themselves competent to deal with the diagnosis and treatment of cancer. With the co-operation and support of his Department, I am quite certain the institutions concerned would carry out an effective propaganda campaign.

Possibly one of the reasons why our statistics in regard to cancer make such gloomy and discouraging reading is the fact that we have spent so little on cancer services over the years. If we spent, as the Minister has pointed out, £17,500,000 per year on the health services, it would be interesting to know what percentage of that went on the anti-cancer campaign. Possibly it may not be practicable to get all these details because I know that cancer is not treated only in the specialist hospitals. A good deal of it is treated by surgery in the general hospitals. Last year, about 4,500 new patients were treated in the three cancer hospitals as against about 1,600 in 1950, just seven years previously, so that the amount of State aid and aid through the Hospitals Sweep funds that is given to the specialist cancer hospital, is a fair indication of the amount of money provided by the State for the fight against cancer.

I think the public would be very surprised by the small cost to them of the present cancer services. If, as the Minister points out in his report, one-seventh of all the deaths in the State last year were due to cancer, it would be interesting to know what the percentage of money spent on cancer services amounts to. I think it would be found to be a very tiny fraction and far below the one-seventh alluded to by the Minister.

There is another factor in connection with cancer to which the Minister did not refer and to which I should like to make a brief reference. That is the question of research. Research, as everybody knows, is a very expensive undertaking, an impossible undertaking for a country of this size; but apart from the fact that it is a small country, it is a homogeneous community and we can carry out here some very useful research on questions of statistics, and I think this would be well worth the Minister's support and financial assistance.

I should mention, incidentally, that the system which the cancer hospitals employ in the utilisation of the external diagnostic clinics throughout the country saves the ratepayers and taxpayers a considerable amount of money. Under this system, as probably most Deputies know, the experts from some of the cancer hospitals travel down the country and see the patients there rather than that each patient should have to be sent up from the local authority health centre and have to travel at the local authority's or his own expense. In assessing even the present small cost of cancer services to the State, there should be, in fairness, a setting-off in respect of the amount of money local authorities and individuals are saved. Not only do we run our cancer services at a very small cost but also to the financial advantage of local authorities and the individuals concerned.

In regard to incurable cancer cases, up to recent years, such cases had two options: the patient either went home again and died there, usually in considerable distress and naturally causing considerable distress to his family, or went into one of the homes run, possibly, by a community, and known as a hospice for the dying or a home for incurables. I think that is a feature of the cancer campaign to which the Minister would do very well to direct his attention. Some sort of institution, not a hospital for the dying, but some form of institution where a certain amount of treatment could be made available, should be built. A few of these throughout the country would be sufficient and, if they could be provided, they would be a tremendous asset and addition to our whole cancer campaign. Naturally, every hospital likes to think its function is to cure and not to look after chronic cases, but I think every hospital would admit that the problem of chronic cases needs special and urgent attention. That is certainly true in the case of cancer treatment.

The Minister would be well advised to examine closely the possibility of greater co-ordination of the existing cancer services. I say this, knowing there are difficulties in the way of closer co-ordination or integration, but I feel, of necessity, in our case as a small country, with a small population and limited income, any integration which we can achieve in our cancer services will lead to greater economy and efficiency and give better service in the long run to our patients.

In 1949, a body known as the Consultative Cancer Council reported to the Minister's predecessor, Deputy Dr. Browne, and that report has been largely the basis on which much of to-day's cancer treatment services are founded. The time is now opportune to make that report available to the public. It was compiled by 17 medical and lay experts and is a very fine report on the general cancer position in the country at that date. Its recommendations would also be of considerable value to health authorities and others interested in health and particularly the treatment of cancer.

I do not wish to say anything more about cancer. As the Minister is aware, I could say a lot more: I am, perhaps, more closely identified with the question than any other Deputy. A good deal has been achieved through voluntary organisation at little cost to the State, and I personally think the Minister would do well to continue the anti-cancer campaign through these agencies. In saying that, I have regard to the fact that the question of overall policy is one for his Department, but looking back over what has been achieved, particularly in the past five or six years, I think the record of these voluntary agencies will bear the closest examination by any impartial or expert investigation. Certainly, speaking for myself, I would welcome such an investigation from any authority or commission set up by the Minister.

Several Deputies have spoken about the treatment of mental defectives and I should just like to add to one point made in regard to the care of child mental defectives. Deputies have paid tribute to the communities in their own areas undertaking the care of these mentally defective children and I should like to appeal to the Minister in regard to the community of the Sisters of Charity of St. Vincent de Paul who manage a home for mentally defective children near Limerick City. I think the Minister is aware of the tragic necessity to increase the accommodation in this institution, which was originally a large private house and was acquired by the community some years ago. Its maximum accommodation is 36 children and at present they have 170 children on their waiting list.

Very expansive, and I have no doubt expensive, plans were put before the Minister's Department two or three years ago. I appreciate in present circumstances there is little likelihood that the Minister can give his sanction to go on with these plans, but I should like to add this appeal to a personal appeal I made to him quite recently to sanction at least an increase in the accommodation by 50 or 60. I think every Deputy could tell a truthful and harrowing story of some mentally defective child in its home and the pain and grief it causes parents, and how unhappy such a child is among other children who are fit and well. I would ask the Minister to make a special effort—I know my demand is only one of several—to allocate the necessary funds to increase the bed accommodation in this institution. These good ladies are doing a wonderful work and I think we could afford the necessary funds to give them another 50 or 60 beds.

The question of adult mental defectives was also mentioned. In some of our mental homes, there are persons who would be better described as senile, and I think it should be possible now, through accommodation becoming available, due to the closing down of other institutions, to transfer some of these senile patients to the vacant institutions. Long ago, it was regarded as the duty of children to look after their parents in their advanced years but having regard to the modern complex life we lead, I do not think it is possible now for younger couples, with perhaps four or five children of their own and possibly living in very difficult circumstances, to undertake the care of a parent who may be senile. For that reason, I think that we, as a community, must accept the responsibility of looking after them.

I should also like to appeal to the Minister—this has become an almost annual affair—to increase the very modest grant which he pays to the Medical Research Council. That would be money very well spent. The Medical Research Council is a body which has done a tremendous amount of work in the past. I think I am correct in saying that the present sum is not more than £25,000 or £30,000 which, even in our straitened circumstances, is a very small sum indeed.

Deputy Dr. Browne made reference to the future of the health services here, in particular, making a comparison with the national health service in England and in the Six Counties. I do not think that at the present time we, as a community, however desirable it may be, could accept the financial obligation of a completely free national health scheme. It is inevitable that a free, or almost free, scheme will come some day, but how soon I cannot say. It will come because the people will demand it. The number of people who are just over the border-line are continuing to grow in numbers so that eventually there will be such a demand that whatever Government happens to be in power will be unable to refuse. Eventually, we will have some form of comprehensive State health scheme in this country. If and when that day comes, I hope we will learn from the experience of the British national health scheme.

There is one unit in that scheme which I should like to see preserved free of State and departmental control, that is, the family doctor. Whatever scheme we may evolve, I hope the family doctor will be kept outside it and that the freedom of choice of doctors about which other Deputies spoke will be maintained.

Reference was made to the voluntary health scheme. I must admit that I am very much in favour of that scheme. Even though it is a restricted scheme and does not give some of the benefits it should give, it does provide for a gap in our health services. Unless I am mistaken, I do not think the cost of that scheme compares badly with the cost of the health services as a whole. I think the Minister gave the figure of £5 10s. per head of the population as being the cost of health services. If I understand the terms of the voluntary health scheme correctly, the first scheme costs £12 per year for a husband, wife and four children, which works out at £2 per head, less the income-tax allowance on the premium.

Even though the voluntary health scheme does not provide maternity services—that is its greatest defect—it is a cheap scheme, unless there is some hidden cost in it which I cannot see. It is true that there are other categories where the cost is greater, but even taking the highest scheme, £23 for a husband, wife and children, the average cost is less than £4 per head. There is an allowance for income-tax, which reduces that sum by approximately a further one-third. I do not think it is correct to say that it is far more expensive and far less satisfactory than the per capita cost of the health services as a whole.

Let me end as I began by paying a tribute to all the Ministers who have undertaken this onerous and difficult job of Minister for Health. It is not an easy one. As the Minister quite rightly said, one is caught between the upper and nether millstones of the public demanding more services at less or no cost and, at the same time, crying out against high taxation and rates. I am afraid we cannot have it both ways. Like every other community in the world, we want to have it both ways. The best any Minister can hope to do is to give the best and most efficient and, in the circumstances, the cheapest service the community can afford.

The Minister stated that the very closest scrutiny will be made of our health costs. I hope that same scrutiny will apply to his own Department. I feel that there is no use going down the list to find where to effect economies. The place to economise is at the top. I believe there is room for economy and efficiency in this Department as, indeed, there is in every Department of State.

Mr. Moher

I was prompted to speak by a remark made by Deputy O'Sullivan earlier this afternoon when he referred to the continued and sustained assault now being made on public representatives. It is a growing practice for groups and individuals to assail the public representative whenever they get a platform. I think it is about time we set out to defend ourselves. I think the public representative is a social worker of prime importance, as far as the community is concerned. He has a big job to do even in respect of his co-operation in the operation of the Health Act. He is the person to whom many people, unaware of their rights under the existing health laws, turn for advice. His sympathetic ear is always available to those who consult him. He is, in short, the one person who is ever ready to help the lame dog over the stile.

I listened for the greater part of the day to a number of speakers referring to the care of mental defectives. Anyone who has any idea of the problem is well aware that, by comparison with the development in Great Britain, we are very far behind, but many of the Deputies who spoke seem to think that the care and rehabilitation of mental defectives are simple matters. Those of us who are interested in this problem know quite well that it is a complex business.

One has only to study the developments in Great Britain to realise the tremendous problem we have to face here. The care, hospitalisation and, in some instances, the rehabilitation of mental defectives are no simple matters. They require, first of all, specially trained personnel and, in addition, a specific type of building and hospital, because if we are to do the job as it should be done, there must be strict classification. It is no simple problem and as far as undertaking or initiating anything in a comprehensive way is concerned I think the Minister and his Department must turn for the solution to the various local authorities. It can be solved only by approaching it in the various areas where it exists. We must create a consciousness in the various local authorities and county councils before we can undertake to tackle that problem. As I said, there is the provision of the trained personnel which is a very big problem. There is then the provision of the proper type of hospital, to facilitate the segregation of the various types of defectives.

The tragedy is that of the few institutions we have they are not able to provide an answer for the enormous problem which faces us. The very fact that the facilities are not available places those who want to get a census of the number of mental defectives, in particular mentally defective children, in a difficult position. You cannot make a reliable census, for the simple reason that the people to whom the facilities are not available are not prepared to declare the fact that they have in their family a mentally defective child. One of the greatest calamities that can befall a married couple is for them to have born to them a physically or mentally defective child. The mother is the person to whom must go the greatest sympathy because the care of a mentally defective child is never ended. The mother is continually on the alert. Apart from that, it is unfair to the parent and unfair to the other children.

There is the fact that we do not know what impact a mentally defective in a family may have on the normal children in that family. I know one instance of a mother with ten children, one of whom was a mental defective, a little girl of eight or ten years of age, and when the mother has occasion to leave the house, there is a special crib provided for that child. The father has a valuation in excess of £50—and the £50 valuation in the part of the constituency that I represent would not be, in acres, a very large farm—and he is debarred from any help whatever from the local authority, and that mother has to face the situation of that child being a continual burden as long as she lives.

With the care of mentally defectives must also go the care of epileptic children. Again, there is no reliable census because the institutions available are not adequate to provide for the care of our epileptic children. The care of such children is a specialist's job. I had occasion some time ago, when in England, to visit one of these institutions that care for something like 250 mentally defective girls. I was amazed at the segregation and the attempts made by the Sisters in charge to rehabilitate these children. One of the features which struck me as extraordinary was that those mentally defective children had in the previous year won the London drama league for juniors and the Sisters had got a concession from the British Ministry of Education whereby the age limit for competitive examinations was increased by two years in the case of certified epileptic children.

Apart from the mental side of the picture, we lack facilities for the rehabilitation of physical defectives, those who are physical defectives from birth and children who have lost a limb through an accident. So far, except what has been done in a voluntary way, we have done very little in the Department of Health in attempting to grapple with these problems.

Various aspects of the operation of the Health Act have been discussed in this debate. Everyone is now convinced that if we had more co-operation, the Health Act could be made a reasonable success. We who are members of local authorities are well aware that there are the limited few who have never tried to co-operate and who in many instances do all kinds of manipulating and stunts to avoid doing anything that would make the Health Act a success. We are well aware of the practice whereby a local practitioner who is a friend of a city specialist manoeuvres a patient in the middle income group into the office of a city specialist and thence to the semi-private or private ward of a hospital. Then the patient is amazed to discover that, even though he or she comes within the valuation limits or the income group, he or she can be regarded and must be regarded as far as the Act is concerned, as a private patient.

In the city, the specialists who do that kind of thing are few. Nevertheless, they are there. We are well aware of that because, when the fish is caught, it is always returned to us. We have complaints, but there is nothing we can do about them. Every Deputy who is a member of a local authority knows that scarcely a week passes but we have complaints by letter, or personally, from individuals who have been manoeuvred into that position.

Recently, I had a case of an old lady living with her married sister. The old lady was an old age pensioner. The sister had no statutory responsibility whatsoever for her hospital treatment. She was advised to go to a certain city office and from there to a certain home. The sister ended up by having to pay, when the old lady died, on her behalf, a charge amounting to something in the region of £70.

I had then the case of the small farmer in my constituency whose wife was sent to the local maternity hospital. It was discovered there that she needed specialist treatment and she was sent to a city hospital. She got the specialist treatment. The doctor charged her 30 guineas and the hospital charged her 67 guineas. That farmer's valuation was £25.

Every member of this House and every member of a local authority is well aware of the manipulations and evasions which take place. One of the defects in the present system is that the ordinary citizen is not conscious of, or is not educated, as to his rights under the various provisions of the Health Act. We are well aware that eminent surgeons and physicians in city hospitals do excellent work in trying to make the Health Act a success and it is very discouraging for them that a few mercenary-minded colleagues should do nothing except collect the guineas. That is the position.

There is also a suspicion—I am sure that the Department will have some information in connection with the matter—that certain hospitals which have contracted to operate the Act have carried out certain internal reconstruction work and, in that reconstruction, have reduced the number of public beds and created extra semi-private wards. The Minister should take particular note of the reasons advanced for internal reconstruction. There are suspicions. There appears to be a very definite reason why the number of public beds should be reduced and the number of private and semi-private increased.

I have said a good deal on the side of the patients. To some degree, I have assailed the doctors. Remember, we have in the general public some very cute people. It would be unfair to give one side of the picture, without giving the other. We have the people who will go to the private consulting room of the city specialist and enter the semi-private ward of some voluntary hospital, knowing full well that they are not covered by the Health Act, except in so far as the local authority is liable to make a contribution. Immediately they are treated, they quite coolly turn to the doctor and say: "Apply to the county council." Those of us who are members of local authorities have come across these individuals. They think that, because there is a Health Act, they can evade their responsibilities. I have no sympathy whatsoever with that type of patient.

There was a reference here to an editorial which appeared in the Journal of the Irish Medical Association, April, 1958, under the heading “Ten Fruitful Years.” I shall quote a few extracts:

"From all sides doctors had been pressing for improvement in the health services of the country, and a new Health Act (1947) foreshadowed an increasing interest in Government circles in the health of the people. The Department of Health was no longer to be an appanage of Local Government, but a Ministry of Health per se, and Ireland's first Minister for Health, a medical man by profession, with long antecedent experience of political administration, had taken up office. But, in the drafting of the Bill, no consultation of the Association by the Minister or his Government had been forthcoming”

Anybody who followed the history of the introduction of the various health services is well aware of the fact that no representations were ever made by the representative body of the Irish Medical Association for improved health services. I believe the very opposite was the case. It is well known —it is on record—that they opposed not alone the 1953 Act but the 1945 Act as well.

"In March, 1948, with a change of Government a new Minister for Health, young and enthusiastic, but lacking all administrative experience, entered on office. A new mother and child welfare scheme, of strongly Socialistic tendency, threatened to affect the status of the private practitioner, the dispensary doctor, and the honorary staffs of the lying-in hospitals, to say nothing of the private lives of families of all classes. The new concept of ‘Social Medicine' enunciated by Ryle at Oxford was apparently to be translated to this country as ‘Socialised' medicine, and the Minister apparently conceived that the arrangement of the postgraduate education of doctors was also a matter for his Department. (His noisier, but more experienced counterpart in Britain had been careful to leave such direction wholly in the hands of the universities and the medical schools.)"

There is, of course, a pattern in that. The bouquet gives forth many divergent perfumes. Since every section of the community and, in particular, the poorer sections have had made available to them specialist and other services, then every member of this House, is a socialist, because every member of this House was glad that there was at last equality of opportunity, so far as the treatment of illness is concerned.

"The history of the past five years is fresh within the memories of all, and needs no recapitulation here. But that the influence of the association which helped to bring down a Government determined to ‘socialise' the practice of medicine in obedience to its ukase in 1953 was the outcome of the five preceding years of building is a fair and just conclusion."

I am sure every Deputy would be surprised to infer from that quotation that we have in the office of the Irish Medical Association a political commissar, a person who will decide when and by what means to assail the Government elected by the people. Obviously they are far more interested in politics than in medicine. They had better address themselves to something more relevant to the job they are supposed to do. After all, they collect guineas from practitioners down the country and should be much more interested in medicine than in the downfall of any particular Government.

In my county and constituency, we have had some experience of what these people can do when they band themselves into what one might call a trade union. Some two or three years ago, we had the painful experience in Cork of being told by a group of these people, who banded themselves into a trade union but called themselves by an unpronounceable Latin name, that they reserved the right to charge the children of those parents who they deemed could afford to pay under the school medical services. In other words here was an example of a direct challenge to what was the law of the land. The children, under the school medical services, are guaranteed treatment for certain ailments, irrespective of what the means of their parents may be; but here we had a group who banded themselves into a society and told the local authority they would reserve the right to charge the parents of children they deemed could pay.

The local authority was well aware that they could not negotiate on that basis. There was not a strike, but there was something akin to a strike. We found within a short time that the number of children notified for treatment by the various school doctors began to increase. We reached the position where we had a waiting list of well over 1,000 children. Of course, they did collect the guineas for the very simple reason that the children of the people who could afford, or nearly afford, to pay went ahead and had their children treated.

The position of children whose parents could not pay, however, was quite different. We had the appalling situation of tonsillitis cases becoming complicated and we had children suffering from such diseases as mastoid ear. Finally—and all credit to the present Minister for Health—the only solution was to employ a doctor on a sessional basis to treat the more acute cases. I am glad to say that the more acute cases of those who suffered as a result of what I might call the strike have now been treated.

The Health Act is in operation long enough now to show any deficiencies which such an Act is bound to contain. The time is ripe for a re-examination by the Minister, the Department, the doctors and the local authorities of the difficulties that exist in the light of the operation of the Act.

Mr. Larkin

Like other Deputies, I feel compelled to open my remarks by paying tribute to the present Minister and his predecessor. I regret that my tribute must of necessity be a backhanded one because the remarkable success of both of these Ministers has been their success in cutting costs and, in so doing, continuing to inflict hardship on those of our community least well able to suffer hardship.

With my colleagues in the Labour Party, I supported the introduction of the 1954 Act. My colleagues in the Labour Party in 1953 also supported the Act of that year. I do not think any of us visualised at that time the confusion and the sense of utter frustration which could be brought about by the operation of one particular section of that Act, a section borrowed from the old Public Assistance Acts. Speaking roughly, that section says that certain services will be provided free for those who are unable to provide through their own resources, the services for themselves. That section has been a source of trouble, difficulty and hardship to many thousands of families throughout the country and in particular to many thousands of families in the City of Dublin.

In paying tribute to the successive Ministers for Health, I must include their ability, on any occasion when Deputies attempt to indicate the suffering being caused by the way the Act is implemented, to say they can do nothing in the matter. Of necessity we accept the categorical statements of Ministers here. But when dealing with these matters, year after year, the responsible Minister has to fall back on the statement that he can do nothing about it, in my opinion that is justification for a re-examination of the whole Act, and in particular the section to which I referred, with a view to seeing whether proper effect is being given to the provisions of the Act.

I wonder if the relatively happy position we are in because of the very substantial drop in the demand for beds in tuberculosis institutions would ever have been achieved if one of the overriding considerations in dealing with that disease was the question of cost and not, as was, is, and as I hope will continue to be the case, but in a rather more generous manner, the absolute necessity to deal with the disease on the basis of the interest of the community. The eradication of tuberculosis was approached from the point of view, not as to whether the construction of sanatoria and the investigation and development of new medical and surgical treatments were justified financially, but from the point of view as to whether they would prove successful. To-day we can all join gladly with the Minister for Health in saying how pleased we are that it is possible to close down sanatoria and to use them, possibly, for some other purpose.

That has been the approach to the question of eradicating tuberculosis. I wonder if we have had or will have the same approach or will attempt the same all-out national effort to deal with cancer. It is becoming more evident as each year passes that it is not possible to deal with the problems arising from the increasing incidence of cancer unless as a community we are prepared to cope with the problem in the same way as we coped with the problem of tuberculosis. From the point of view of medicine, the problem is a very different one from the problem of dealing with tuberculosis.

Deputies and citizens have been reading from time to time the various learned opinions as to the factors which encourage the development of cancer. I would ask the Minister, when replying to the debate, not just to mention again, as he has done on previous occasions, the view of his Department as to the effect of tobacco smoking but to say whether his Department has made any research into the suggestion that one of the factors causing the increase in the incidence of cancer is the increased use of diesel and other oils. References have been made in various news organs in recent months to the fact that where these oils are in intensive use cancer appears to be more prevalent than in other places. I am sure that the Minister for Health, his Department and any local authority or any others connected with health services would receive the full and unqualified support, not only of every Deputy, but of every section of public opinion outside the House in any definite and productive effort to deal with cancer.

There is another infectious disease which has been the cause of great worry, particularly to parents—poliomyelitis. In recent years, vaccines have been developed which appear to be able to counteract or prevent the disease to a great extent. In an effort to deal with a disease that was prevalent in the early part of the century most children were vaccinated. Whether it was the result of vaccination or not, smallpox became practically unknown in this country. In recent years, immunisation has proved most successful in the prevention of diphtheria. Unfortunately, from time to time some of us failed to realise the necessity for putting ourselves on our guard.

There is hardly a Deputy in the House who does not know of the sad death of a little boy or girl occasioned because the parents were a little too confident, or because the parents hesitated in having their children immunised. They put off visiting a doctor or local health centre, for one reason or another, until it was too late. Many of us in the House have had personal knowledge of friends or relatives who suffered the loss of a child, not through wilful carelessness but, in the main, due to delay in having the child immunised.

The effectiveness of vaccination for smallpox, and of immunisation for diphtheria, surely increases to a great extent the desirability of ascertaining whether or not the system of vaccination and immunisation will protect our citizens against poliomyelitis. If the Minister for Health, advised by the competent medical officers of his Department, in conjunction with the experience of surgeons throughout the country, formed the opinion that treatment was desirable, I would suggest that no section of public opinion would oppose the added expenditure arising from the necessity to import any particular vaccine for the purpose. Treatment of diseases like poliomyelitis, diphtheria, cancer and tuberculosis, cannot rest on the basis of whether there are financial difficulties at the particular moment or not. They must, in my opinion, be dealt with on the basis that we can afford to spend the money.

Reference has been made in the course of the debate to the growing need for educational accommodation for mentally defective children. There are many communities giving devoted care to mentally defective children, both boys and girls. In addition to children who are mentally defective and unable to look after themselves there is the question of mentally retarded children who are not 100 per cent. normal. Yet, with proper care and treatment they may be enabled to take their part in life as useful citizens when they grow up. While this may not be entirely a problem for the Minister for Health I would ask him to use his good offices, where necessary, with his colleague, the Minister for Education, in connection with such children who can be trained but for whom there is insufficient training accommodation, and for whom there is insufficient money at the present time. I would join my voice with that of others in appealing to the Minister not to be in any way niggardly with whatever finances he may be able to muster in helping to have adequate provision made for these children.

I am a member of one of the largest mental hospital authorities in the country. In two of its institutions the patient roll is approximately 3,000. In them there is a unit which holds about 20 mentally defective children, and I suggest to the Minister that no matter how good a mental hospital may be, no mental hospital which caters for adult mental patients should also be required to cater for mentally defective children. I would suggest that the problem of looking after such children is, to a great degree, divorced from the problems that mental nurses normally meet in the discharge of their duties. These children should be looked after in special institutions.

Might I, having mentioned the question of mentally defective children, also briefly refer to the position of the large number of aged or senile patients in some of our mental hospitals? Those of us who are on mental hospital boards, and who have visited these institutions as part of our duties, have been struck by the numbers of aged patients who are apparently mainly weak-minded, but whose main desire is to leave the institutions. It has been my experience on many occasions, on inquiring as to whether a particular patient or patients could leave, that I have been informed by the responsible medical officer that they could leave if they had anywhere to go—if they had any relatives who would look after them. The problem in many cases, I am afraid, may be economic. It may be financial or it may be just a purely human problem.

As the average family to-day has to face such a struggle to provide for normal day-to-day existence, it is quite conceivable that a number of these patients might not be in the institutions were it not for the fact that their relatives are not in a position to look after them properly. When I say "look after" I do not mean just to provide them with a bed and their meals. Many of them require a little more care than just bed and meals. They require somebody to be near them for a good portion of the day.

There are few families in Ireland who can afford either to have some member remain out of employment or who can afford to pay somebody for looking after an elderly relative who requires constant care and attention. We know that many hundreds of families suffer a great deal of inconvenience and forgo a great deal of personal pleasure and recreation in order to devote themselves to a member of their family who is ill or old but there are still quite a lot of aged patients in our mental hospitals who, given the opportunity, would go home.

It is visualised that, in the near future, efforts will be made to provide accommodation for these patients in institutions. I hope and trust that these institutions will not be just institutions where the patients are brought in, left there and given the minimum care and attention but rather that they will get the specialised care and attention in them which the old, the weak and the feeble need.

While making reference to this particular aspect of the care of the mentally ill, might I once again ask the Minister: Is it not time that the position of mental hospitals was reviewed? Many of them were at one time workhouses. From every point of view, our mental hospitals should be brought into line with the general modern approach to the treatment of people suffering from any other disease. In this year of 1958, there is still far too much overcrowding in our mental hospitals. Although the Mental Hospitals (Treatment) Act, 1946, the developments with medicine and particularly, in recent years, the introduction and use of the new tranquillising drugs have all aided considerably, there is still a position in which nobody in this country who has any connection with a mental hospital can afford to be the least bit proud of that fact.

In the hospitals with which I am associated, a large number of patients dine in the one dining-hall. Patients suffering from different forms of mental illness, patients who enter the mental hospital voluntarily in the hope that—as frequently happens— they will be able to resume their normal life after a period of treatment, and patients who are capable of working on the farms of the institution or of taking part in the various activities, are all compelled to dine at tables right beside some of the unfortunate mentally ill who are unable to feed themselves properly, who are unable to use the cutlery. We still have far too many patients congregated in single divisions.

In recent years, an attempt has been made to bring the standards of mental hospitals up to a higher level. It may be possible in the near future to expedite that matter because of the fact that some institutions will become available. Nevertheless, too many of our mental hospitals are situated in buildings which up to recently were workhouses or prisons and which are utterly and completely unsuited for the modern treatment of mental illness.

Finally, I might say to the Minister —possibly I may be going outside the strict terms of this debate but nevertheless I think it must be said—that the sick in our hospitals whether general, specialist or mental hospitals, cannot benefit to the fullest extent from medical treatment, rest, care or surgery unless those whose duty it is to look after them and nurse them are also treated in a proper way. One wonders whether the nursing staffs in the various hospitals throughout the country are treated in a proper way when we see the turn-over in the number of nurses and the constant flow out of the hospitals of nurses, partially or fully trained, whose services could be of inestimable value to our patients. I do not think we always realise the value to the sick in our hospitals of medical and nursing staffs who feel that they themselves are being treated properly.

As regards the City of Dublin, we have a very significant problem in that regard. Through the development of the Health Act, health regulations and health legislation, and the parallel development of our City and County Management Act, we have a situation wherein an official is responsible for the administration of quite a large number of institutions and for practically the whole health machinery in the City of Dublin. Because of this administrative chaos, he is able to devote only one half-day per month to looking after the administrative affairs of two mental hospitals, Grangegorman and Portrane, at present St. Brendan's and St. Ita's, and may be unable—I do not know—to deal with the problems that arise, in a sufficiently efficient and expeditious manner so as to avoid the development, over a period of weeks, months or even years, of a spirit of resentment among the nursing staffs of institutions on whom is placed the day-to-day care of the patients.

Hand in hand with the difficulties which have developed from the health legislation and the Health Act of 1954 goes the whole administration of health in this city. It is not confined to administration of hospitals. I think it has its most glaring example in the administration of schemes which are utilised to extract money from those who require hospitalisation for themselves or the members of their families. Under this heading, might I mention that one of the main arguments and main theories used by all those who supported the Health Act of 1954 was the theory about the card now referred to all over the City of Dublin—I shall not speak about the rural areas, as they can look after their own problems —as a "blue card". The introduction of this medical services register and the supply of the blue card, it was intended, would take away from the people the ignominy of having to go, week after week, to the dispensary doctor or the relieving officer if they required any health treatment.

The difficulty, the biggest source of disappointment, is that the introduction of this blue card has not had that effect. Even though families are registered in the medical services register, on each occasion when the person so registered, or a member of his family, requires treatment he has to go through the same system of query as to his needs and his means as if he never had that card at all. In theory, this card entitled him to certain services and it was visualised that a person having it would just go along and present the card and get the services without question. But we in this country never seem to be able to plumb the tortuous depths of the officials' minds. Possibly we have forgotten that there was more than one service covered by this registration. If we got at the person who had the card, who received the benefit of one, then we have to make a thorough investigation in the case of members of that family who require the service. Consequently, we have the position to-day that persons who go under the scheme for examination of the eyes and the provision of glasses, are in many cases so disgusted at what goes on, and the official queries bound up with it, that they finish up by going into Woolworth's, buying themselves a pair of glasses and taking a chance on their eyesight or they finish up by being supplied with one of those old metal type glasses which used to be supplied years ago.

Then we come to this glorious example of what happens when officials get directions to "cut costs". The sum of 10/- per day is payable by those who qualify as insured workers and who are in the lower middle income groups. A person who qualifies for hospital treatment on the basis of a maximum charge of 10/- a day may, in many cases in our city, be a labourer with the average rate to-day of £7 10s. a week, or may be a clerical worker, a shop assistant, a white collar worker, with a salary in or around the same scale. These rates do not provide any margin and certainly they do not provide for cases where the wage earner has to spend periods of two or three weeks, a month or a couple of months, under treatment in hospital.

In many cases, the only family income then is national health insurance. It does not provide for the family having to live on the reduced income for that period. The average income to-day does not provide that, when the wage earner or salary earner resumes his duty, he can pay sums each week in addition to the normal outgoings. He has not got that balance.

In certain cases, of course, an applicant makes an appeal. The officials dealing with the matter, in so far as lies in their power, are usually inclined to be reasonably sympathetic, but in many cases, the appeal is not allowed. The applicant may then come to a local representative, his Deputy or councillor. This, I think, is one of the features of the scheme. It is most unsatisfactory that the Deputy or councillor can make representations and, in certain cases—I am not saying in all cases—a reduction will be made, and nobody knows whether the reduction was made basically because equity and justice decided that the amount of the hospital bill should be reduced, or because the Deputy or councillor was able to influence the decision. I do not say that that is done in any underhand way, but, because of the representations by a Deputy or councillor, £5 or £10 is struck off and in a similar case, where there is no Deputy or councillor involved, the person has to pay or go to court. That aspect of the matter is most unsatisfactory.

The situation in regard to these services appears to be that, instead of the original position where the person got a pink card and got the services, now they may get the blue card and not get the services, or not get the blue card and get the services. The decision, as far as I know, is left with a high official or somebody acting on his behalf. Certainly I suggest, in all sincerity, to the Minister that the time is now overdue for the operations of this Act to be reviewed. I would also suggest that the Minister might consider that it would work out much more equitably for all sections of the community, if health services were brought within the scope of a reasonably adequate insurance scheme.

The words "free medical services" are very frequently quoted inside and outside the House. We know it has been found possible to provide certain services without direct charge, such as tuberculosis services and services for schoolchildren and so on, but we in the Labour Party are under no illusions. when the word "free" is used. We know they will be paid for and we know that, whether you use the word "free" or not, the bulk of the payment will come from the people who contribute to the country's economy, by the work they do, whatever particular form it may take, whether it is the contribution of those in the rural community producing the necessaries of life from the land, of those engaged in transport undertakings, the various industrial undertakings, or the contributions of those in our offices and shops, or even of the very much abused Civil Service. If the health services, hospitalisation and medical services were based on an insurance principle, two things could readily be ascertained —the amount being charged and the type of service one is entitled to get.

Unfortunately, at the present time, it is very difficult to find out who is paying what in regard to the health services because we have the system of double payment—it might be called "double indemnity". The taxpayer pays so much and so much is levied on the ratepayer. Accordingly, we have members of this House who are members of local authorities—even I myself may, on occasion—standing up in the local councils and drawing attention to the terrible injustice of having any health or social services charged against the rates of that local authority.

There are very few local authority members of the House with whom I am acquainted who have not, on one occasion or another, made very eloquent speeches in support of the proposition that all health and social services should be borne by the taxpayer. Consequently, we have the system of national payment and a grant to the local authorities in respect of 50 per cent. of their approved expenditure. I think if the situation were examined— and we have had experience now since 1954—we might be able to arrive at a more reasonable, more logical and more humane approach to this question of our health services.

Finally, might I close as I began, on a note of criticism? This is April, 1958, and we are very close to the month of May. It was, I think, in 1941 that there were incidents which cost the lives of a number of Dublin citizens. On one of the main roads leading out of Dublin, the North Strand, we can still see, 17 years afterwards, mark you, the empty space where houses and shops formerly stood. I understand that, for a period of eight or nine years at least, very serious consideration was being given to the erection of a health clinic on a portion of that site, which is referred to in Dublin as "the bombed area". The space is still empty. Like many of my colleagues in Dublin Corporation who have become so confused as to what is happening, I do not know whether the clinic will ever be built.

It was also our experience generally in the years prior to the war, when housing in the City of Dublin stepped up rapidly and when housing estates were being built in various outer sections of the city, that continual representations had to be made in connection with the provision of health clinics in these areas. I have no doubt that the Minister for Health, who is a very able man, would have some idea of what is going on generally in Dublin, and if not, he would have no difficulty in finding out from his colleague, the Minister for Local Government, what were the plans for this type of development. Yet, time after time, each area was planned and completed and the people were living there for one, two or three years without these services and constant representations had to be made.

I do not know if the situation is quite so serious now because of a certain development which, if I were to mention it, might be ruled out of order by the Ceann Comhairle, but I believe the aspects of health administration which I have mentioned could well be examined, not with a view to saving a few thousand pounds—because I believe when we are considering the health of our people the main factor should not be the cost—but from the point of view of ensuring that at least our citizens and their families are getting the services to which they are making such a substantial contribution.

Mr. Moloney

I should like to deal with the question of the issue of health cards and the general dissatisfaction that appears to exist in that connection throughout the country. On the whole, most local authorities—at least where I live, in Kerry—have done a pretty good job in issuing these cards. The Act came into force in such a way that the local authority was faced with the rather formidable task of handling this question of health cards. Overnight, the system of red and white tickets which had existed went out of operation and was replaced by an interim arrangement, involving the issue of special tickets by wardens and members of local authorities, until the health cards were issued.

Most people who had hitherto benefited through the dispensary system by way of free assistance for medical attendance, medicine and certain appliances felt they were automatically entitled to be holders of health cards under the new arrangement. For very good reasons, however, this did not work out in practice, and I am inclined to agree that all the people who were fortunate enough to have the advantage of free medical services before the passing of the Health Act were not entitled to them.

A very important change had taken place as regards workers' incomes over the past 15 or 20 years and it was quite obvious that a ceiling had to be fixed somewhere in regard to provision of medical attention and appliances, medicine and so on. At the start, the health authorities were, if anything, rather on the loose side regarding granting medical cards. Unfortunately, the applicants in most cases were not very co-operative. It was understood that the question of income would be taken into consideration and would be a very important factor from the point of view of the health authority in giving the card or otherwise. A very large number of applications had come in and in most cases the applicants were clamouring for an early decision.

The investigation it was possible to carry out was a bit haphazard and it is natural to expect that quite a lot of inconsistencies were bound to occur. Many instances have been brought to notice of people in receipt of £5 or £6 a week who were unable to get health cards, whereas their neighbours with the same income and probably the same number of dependents succeeded in getting them. These matters are not important; they are trivial in themselves and do not justify a general condemnation of the administration of the Act.

We are all aware that for the past five or six months there has been a general reinvestigation of the system; most health authorities have initiated an inquiry now into the means and incomes of the holders of health cards. I think when that investigation is completed, even though it will hurt some people, it will certainly be of benefit on the whole.

I rather think that the task imposed on assistance officers of investigating and reporting on these cases is a bit beyond them. It would be a considerable help to those officers, if there was some system of spot check. After all, assistance officers living locally in the district are there to help the people generally in times of distress and it is quite on the cards that, when an application for a health card is refused, the blame will immediately be laid on the local assistance officer. The relations that will exist at a later date between such people and the assistance officers leave much to be desired. I think that county managers, even though at the present moment they are probably not in a position to appoint any special investigating officers, could second some officers from the existing staff to act as spot checkers on the reports of assistance officers in the case of applications for health cards.

Cases where there is doubt and where the applicant is dissatisfied with the decision of the local officer might, in the first instance, be referred to somebody in the local authority for a second opinion. A number of people seem to think that there should be a right of appeal. I agree with that. If we give the right of appeal to everybody, they will certainly take advantage of it. Most of the cases in respect of which there is any dissatisfaction would come up to the local authority where the appeal could be dealt with and a good deal of dissatisfaction could be eliminated in that way.

It has come to my notice that certain dispensary doctors—happily, not too many—are inclined, when cards are presented, to give certain opinions as to the propriety of issuing these cards. Two cases came to my notice where doctors told the holders of these cards that, in their opinion, they were not entitled to have them and that they would see that something was done about it. If the doctor has reason to believe the holder is not entitled to the card, the proper attitude for him to adopt, in my opinion, is to report the facts to the local authority, but under no circumstances should the doctor be allowed to indicate his disapproval or otherwise to the holder of the card. I should like the Minister to make a note of that point, so that the matter may be taken up with the local authorities and that the practice of making references of that nature will be discontinued.

With regard to the middle income group and the maximum charge of 10/- per day, I think quite a number of people have not gone to the trouble of finding out how that charge operates. In my opinion, there is a good lot of unwarranted propaganda in connection with the charges. I do not know if all local authorities have adopted a schedule of charges in that connection, but the local authority in my constituency has a chart prepared in connection with it. I think the whole basis of the charge is operated on a very satisfactory level. The valuation is grouped in £5 groups from £10 to £15; £16 to £20; £21 to £30; £31 to £40 and £41 to £50. The number of dependents of the person concerned is taken into account. A person with an average valuation of from £16 to £20 with three dependents has to pay only 4/- a day.

We are told, particularly by Opposition speakers, that, in practice, the 10/- per day which operates is both a minimum and a maximum. I have given the House those figures from the return I have before me to prove that, in the case of our local authority, that is not so. I am pretty sure the same position exists generally throughout the country. I hope that the basis of charge to which I have referred will be very clearly understood by the middle income group, because they get unduly alarmed at the prospect of 10/- per day facing them. Very often, the charge works out at considerably under that. The same basis of charge applies to middle income group wage earners and the charge is assessed at various stages between £300 and £599. It works out somewhat similarly to the valuation groups to which I have referred.

I should like to appeal to the Minister to encourage local authorities to undertake a general reorganisation of dispensary areas and districts. I assume that such a reorganisation is possible, without any new legislation being required. These dispensary districts were formed many years ago— possibly 60 years ago—and except in very few cases have never been, as far as I know, changed since. The development in housing and certain other amenities for the rural population particularly have changed the whole face of most dispensary areas.

The same applies to urban areas. The existing districts were formed from a number of electoral divisions which were welded together. At the present moment, they are proving very unworkable for dispensary officers, assistance officers and more particularly for the people living in outlying areas who have cause to use the dispensary services. I think the time has arrived when a general re-distribution of these dispensary districts could be undertaken.

I do not suggest that the purpose of this is to extend the number of districts or increase them in any way. In fact, if anything, I think there is a good chance that, in some counties, the number could be reduced. I am nearly certain that, with a bit of give and take on the part of existing medical officers, a more workable arrangement could be come to. In fact, I know that several of the medical officers are very anxious that such a reorganisation should take place.

There is another matter which might be looked into also in connection with the centre of residence of medical officers. Under existing regulations, neither the local authority nor the Minister has any authority or jurisdiction in connection with the place of residence of the dispensary medical officers, once it is situated in the dispensary area. I think the siting of these residences, particularly where residences are being erected by the local authority, is a very important matter. We find in quite a lot of dispensary districts that the medical officer lives very often at an inconvenient part of the district and that people who have to go to the medical officer for consultation are obliged, in the majority of cases, to travel long distances and are put to a certain amount of inconvenience that would normally be avoided, if there was a sensible approach to this question.

There is also the question of locums for dispensary doctors. I understand this is a bone of contention in most areas, probably due to the fact that there are not sufficient medical practitioners available to put on the panel which is usually kept by every local authority. It happens quite often that a locum is appointed from an outside district and continues to live in the outside district, while performing locum work for the period that the medical officer in question is away.

That is a position that should be discouraged as far as possible.

Most of the patients on the doctor's panel are not usually aware that the dispensary officer will be absent and, in the first instance, they will proceed to his place of residence for the purpose of requisitioning his services to find that he is on holidays or sick and has been replaced by a certain locum. If that locum lived in the area adjacent to the usual place of residence of the regular practitioner, the person who wants him is not put to very much inconvenience, but very often he has to cycle or telephone to some place which may be four or five miles away. The result is that a great deal of time may elapse before he is able to contact the locum. The regulations in this connection should be tightened up considerably.

I am glad to notice that there is a greater tendency towards the improvement of dispensary clinics. Those clinics, many of which have been built maybe 100 or 150 years, are mainly very shabby buildings and are by no means comfortable. They are generally without waiting rooms, and patients who are waiting for doctors in these places are not very comfortable. I am glad to note that the attitude of the Minister in that connection is satisfactory from the local authority point of view, and that local authorities are being encouraged as far as possible to replace those insanitary and uncomfortable buildings with buildings of a more modern trend.

Mr. Coburn

Coupled with this Estimate is the Labour Party's motion to the effect that the time has come for the Health Act to be amended in certain respects. Most Deputies will agree that, since the inception of the Health Act in 1953, a certain amount of progress has been made. We all know that the aims of this Act are to make the people who live in this country healthier, and therefore happier and more contented.

We cannot, however, close our eyes to the fact that, in the past three or four years since the passing of this Act, there has been a certain amount of confusion and a number of grievances and complaints. It is a very flexible Act and affords so much latitude that it appears that the county manager in each county has a different interpretation of its implications, and even though varying interpretations are carried out, they all still conform to the regulations contained in the Act. That is one of the main reasons why there is so much confusion and uncertainty as to what is what.

This year, we are spending approximately £16,000,000 on the health services. Over £8,000,000 is being provided by the various county councils and the rest is being provided by the State. That is a very large sum, but, having taken upon ourselves the responsibility of trying to make this country a healthier country in which to live, we cannot quibble if we are presented with such a bill, formidable though it may seem.

Much reference has been made to the various systems carried out with regard to the various applicants for the services in this Health Act, people who are looking for medical cards and people who are looking for practically free treatment in the hospital. As I said, each county manager appears to have a different system of interpreting the Act. In my own County of Louth, it is the practice to send out the assistance officer to each applicant who seeks the benefit of the Health Act. That person makes his report. He ascertains the means of the applicant and not only the means of the applicant, but the means of the whole family. That is where many people are making a mistake. They think it is only the means of the individual person who applies for the benefit of the Act that are concerned. We know, of course, if we read the Act, that it is the total family income which has a bearing on the case, the total unmarried family income; the incomes of married sons and married daughters are not taken into account. That assistance officer reports back to our county medical officer of health who, in turn, sends up his report to the county secretary. Eventually, it reaches the manager who decides on the particular case.

That is a very fair system. I do not know how anyone can condemn it or argue against it. If arguments are to be made or listened to, the people who condemn such practices should be able to suggest an alternative arrangement whereby these problems may be solved.

With regard to patients going to hospitals and being charged fees and finding themselves in semi-private wards when they could easily have been put into a public ward, one of the main reasons for that is that the doctors to whom these people go for attention in their home town do not inform them that if they go to a public ward, they will not be charged more than 10/- per day whereas if they go to a semi-private or a private ward, they will be liable for whatever the hospital may charge them, subject to a contribution made by the local authority of 8/- per day. It should be impressed on the doctors that they should always inform their patients that they have the choice of going to a public ward or, alternatively, to a semi-private ward.

Another grievance which many people have relates to the ceiling figure which obtains in the Act under which a person qualifies for the benefits in the Act. The maximum salary which a person may earn in order to be entitled to benefit is £600 or, in the case of a farmer, a valuation of anything up to £50. It is very definitely a bone of contention amongst people who are earning say £620, or farmers with valuations of £53 or £54, that they are debarred from the benefit of the Act. I know there is provision which says that the county manager may use his discretion and allow a certain amount of benefit in certain cases. In the main, I think there are very few cases in which the manager uses that discretion. There are many people in the over £600 per annum bracket and many farmers over the £50 valuation who are paying towards the cost of this Act. I suggest that the ceiling figure of £600 and the £50 valuation should be increased or else the managers should be asked to be a little bit more lenient. If that is done, more justice will be meted out to all concerned.

Reference has been made to doctors reporting people who are not entitled to medical cards. I am not aware of any case where that has happened, but I would imagine that the doctor, being human, and having to live just as well as other people, must necessarily look to his own interests. If a patient goes to a doctor with a medical card, the doctor treats that patient and does not obtain any fee from the patient. The doctor is paid a fixed salary by the local authority. If a private patient goes he must pay. Every private patient must pay his doctor. If a patient comes with a medical card and that patient is not entitled to the card, the doctor rightly condemns such a practice and rightly, in my opinion, should report that case.

Deputy O'Higgins last week said that people who have medical cards should have a choice of doctor in the same way as there is a choice of doctor in the case of maternity patients. I do not see why people with medical cards should not have the same privilege. That might entail a slight addition in expenditure but, assuming a number of doctors decide to come in under the scheme, I think the Minister would be well advised to consider Deputy O'Higgins's suggestion.

I was glad to learn that the figures for tuberculosis are considerably down. The Minister said that during the past ten years the incidence of the disease had been reduced considerably. Unfortunately, we cannot say the same with regard to cancer. As far as tuberculosis is concerned, we have made some progress. This year in my county we are providing less money for tuberculosis purposes. What we have spent in eradicating this disease has been money well spent. Added to that, we have the progress made in medical research, the discovery of new drugs, up-to-date surgery and modern equipment. All these have resulted in the closing down of many of our sanatoria.

These sanatoria should now be adapted for general hospital purposes. It is only natural that people might react unfavourably to them in the beginning because of fear of contracting tuberculosis. Doubtless that fear could be eradicated from people's minds with proper education. If the sanatoria were adapted for general hospital purposes Hospitals Trust moneys would be saved and we would not be under the necessity to build so many lavish hospitals. Indeed, the building of so many hospitals is in itself a reflection on the general state of the people. Remember, our health is presumably improving. If that is so, the spending of so many millions of pounds on the erection of hospitals is so much waste. If our health is improving and our population is declining, as we are told it is, then I fail to see the need for so many new hospitals. If we adapt our sanatoria for the purposes I have suggested we shall save a lot of money, money which can be used more profitably in other directions.

Reference was made to the congestion that exists in many of our mental hospitals. I am a member of the visiting committee of the Ardee mental hospital. When I see these unfortunate people every month I often think that no effort should be spared to try to help them. There are many people there, and I am sure this is true of other mental hospitals as well, who should not be there. They are there merely because they are old, feeble, senile or slightly eccentric. They are quite definitely not mentally deranged. Now if they are in association with those who are mentally deranged, it is not long before they become mentally deranged themselves. If they cannot be removed altogether, they should be at least segregated. Some of our redundant sanatoria could be adapted as homes for these elderly people. That would be a step forward.

Somebody said during the course of the debate that married couples should not be expected to look after their parents nowadays with the same earnestness that their parents looked after their fathers and mothers in the past. Those were not the exact words used; I am paraphrasing them but that was the suggestion. I say that nobody has any right, authority or power to delegate his responsibility or to transfer his responsibility to his neighbours. That is what happens when aged parents are put into homes. They are maintained there by the general public, by the neighbours, in other words. Where elderly people could be kept at home it is a disgrace to have them incarcerated in these mental hospitals. It is a condemnation of those who resort to this device to get rid of their responsibilities. No matter how old or feeble parents may be, so long as they are not mentally deranged, they should be a charge and a care upon their own children and not upon their neighbours.

With regard to the efforts being made to cure mentally defective children, I should like to join with Deputy Faulkner who paid tribute to the work being done by the Brothers of St. John of God at Drumcar, County Louth. Along with other Orders, they are doing great work for these children. Unfortunately, their complaint is the complaint of many other institutions throughout the country: lack of finance with which to put their plans into operation. If a young person has to go into one of these institutions and is there for a number of years, the maintenance charges can be very high. They represent a very heavy impost on the family which has to pay. I know of one case of a young lad in such an institution. The maintenance charge was about two guineas per week. That went on and on, with the result that the parent had to take the child out, because she could not pay the charge. The charge may seem low per week, but when spread over a number of years, it amounts to a phenomenal figure. I would appeal to the Minister, if he has any spare money, to think of these institutions and the good work they are doing.

With regard to the part of the Minister's speech which dealt with midwives employed by county councils, am I to take it that the past year has been the year of trial, so to speak, in which, if a midwife has not attended 25 cases, she will be dismissed? Is there any particular year when she is on trial?

Mr. MacEntee

The past two years.

Mr. Coburn

If these midwives are dismissed, a number of cases will have to be attended to and this will mean the employment of substitutes. You can call them by another name, but you will still have to employ nurses for this work, and they will have to be paid. I would appeal to the Minister to reconsider his decision and be a little equitable.

I should like to conclude by paying a tribute to the present Minister, his predecessor and the Department in general for their efforts in trying to promote the health of the country. One of the best means which has been adopted in past years to do this has been the use of the mass radiography service through which so many people have been prevented from developing the dreaded disease of tuberculosis. We see people queueing up for an X-ray when the van goes round from town to town. I know of many cases in which the disease was discovered at its inception and, because of this, was easily cured. Such people went into a sanatorium for some months and came out cured. That is the greatest tribute which can be paid to those who thought of this scheme.

Mr. Coogan

We have before us figures that will shock the taxpayers and the ratepayers. We have reached the sum of £17,000,000 for health services. With that figure, I wonder have we got the return in health that the people are entitled to? No doubt, we have a decrease in the death rate from tuberculosis. The old saying is "health means wealth". I wonder what would have been the impact on ratepayers and taxpayers, if we had not had in the past men who established the Irish Hospitals Sweeps at a time when it was called a white elephant? Some of the gentlemen over there may laugh, but we know what the white elephants were on the opposite side.

Recently, we had a visit of high officials from the Department of Health to our Galway regional hospital. On their advice, the county manager advised the county council to accept the tender of the contractor on the site for the demolition of the old hospital. I should like to know why this tender was not put up publicly? The advice of the officials was that the ratepayers were getting a damn good bargain at £5,000. What would have been the result if that building had been offered for sale, like the mansions throughout the country? What would be the effect on the rates in Galway? Instead of losing £5,000, they would have gained at least £5,000, if it had been put up for public auction.

While we have reached a low death rate in regard to tuberculosis, the great scourge of cancer has raised its ugly head. It is a matter of great concern. It has been said that if a person seeks treatment in the early stages, he will have a great chance of recovery. The public should be educated on this matter, just as they have been in regard to tuberculosis. Our schools and the post office service, through the use of slogans, should be used to enlighten the public.

With regard to our mental hospitals, the atmosphere in these hospitals is anything but conducive to a return to normal health. The prison-like atmosphere and the condemned appearance of the buildings are anything but helpful. The Department should take steps to brighten the atmosphere of these hospitals.

I should like to join with other Deputies in paying a tribute to the various religious communities that have accepted responsibility for backward children. It is a vocation of the highest order. I should like, also, to take the opportunity to pay tribute to Irish nurses. No matter where they go, across the Irish Sea or elsewhere, we can be justly proud of them. They are our best ambassadors.

Ambulance drivers should be qualified in first aid. The necessary steps should be taken to instruct them in the elementary rules of first aid because it is important that injured persons should be handled properly and the ambulance driver is generally the first to handle a patient before transfer to hospital.

There is a matter which has not been referred to in the debate, namely, the blood bank. Every Deputy and public man should help the blood bank and should give a lead in this matter by donating blood and not merely give advice or lip service. It is a good in- vestment to donate blood in this way. The Department should play a bigger part in enlightening the public as to the importance of the blood bank and the Department of Posts and Telegraphs could help by issuing slogans asking people to help the blood bank and thereby help themselves.

Reference has been made to mass radiography. All citizens should avail of this service; old people as well as young should be X-rayed. A number of old people now are suffering from tuberculosis. Formerly there were not so many old people in sanatoria. The cinemas should be used for the purpose of propaganda in this matter. That has been done to a certain extent but one cannot have enough of a good thing. The schools also should be used.

Cinemas and dance halls should come under the notice of the health officers. Some of them can be described as veritable tuberculosis sweat boxes, where the light of day never shines. Unless we take every step to prevent disease, it is only waste of money to try to stamp it out. The health officers should get into these places and clean them up.

The Department of Health should interest themselves in the health of children. There are young children running the streets at night. It is a matter for the Department of Justice but let us have a little co-operation between the two Departments. From the point of view of producing healthy citizens and good citizens, it would be better if children were kept off the streets at night.

I would like the Minister to let us know what steps he has taken to deal with a possible outbreak of polio. We know what has happened in the past few years. The Department should be geared to meet a possible future outbreak.

On the question of medical cards, I should like the Minister to state what his views are in regard to old age pensioners. Would they not be justly entitled to medical cards and should they not automatically qualify so as to ensure that they will not have to die for want of proper treatment? I should like to know the Minister's views on that matter.

Mr. Manley

The wide interest shown in this debate proves the importance of the Estimate under discussion. It is quite clear that the Department of Health will be faced with added responsibilities in the years to come. In order to keep pace with medical science and medical discoveries the Department will have to make the provisions that these discoveries will necessitate.

The first essential to good health is a decent home and the wonder to-day is how the health of the people remained so unimpaired through the years when many thousands of the population were compelled to live in very poor homes and very poor houses. It is true that all Governments and local authorities have been very liberal in the provision of houses which were so urgently needed by the people and, with the exception of populous areas like Cork, Dublin and other large centres, we shall be able to say in a few short years that every family is decently housed. The second essential for good health is that the breadwinner in the home is provided with gainful employment in order to maintain the family in decent comfort and that the family will be able to withstand the impact of the various diseases that attack mankind from time to time.

The Minister quoted some very edifyfying figures for us. I was glad that he expressed optimism in regard to the voluntary health insurance scheme because, from rumours we had heard, many thought that that scheme was doomed. The Minister told us that 45,000 applicants had been received for participation in the scheme. I do hope that the scheme will be supported and that, in time, with additional support, the premiums will be made attractive through their competitiveness. It is a pity that we started at the wrong end in that case and that the voluntary health insurance scheme did not take precedence of the Health Act. It would probably have obviated the need for the expensive services that we now provide under the Estimate that is under discussion.

We are also very pleased to hear that the incidence of tuberculosis has been decreasing considerably in recent years, that infant mortality has also declined considerably and that the death rate in recent years was below normal. These, certainly, are features that are largely attributable to better housing conditions, largely traceable, no doubt, to the better health services provided and to the specialist services made available.

The Minister has pointed out that the provision of £17,500,000 is the limit to which we can go in the provision of health services, in our limited circumstances. For the moment we have to bear with that. With the present unemployment position and dwindling population we must use all the capital we have in schemes that will keep people at home. There is no sense in having expensive health services for a dwindling population. We are told that 28 per cent. of our people enjoy free services. It would be interesting if the Minister had a means of computing the number of people in the middle income group who are availing of the partial hospital services provided.

Mention has been made of the Hospitals Trust Fund by various speakers. We should all be grateful to the people who initiated the Hospitals Trust Fund through the Irish Sweepstakes. The beauitful hospitals built by the State during the last ten years typify the wonderful usefulness of that money and show how much it has contributed to the progress of the nation towards good health. Originally, I believe the Hospitals Trust Fund was available solely for voluntary hospitals. Now that the fund has been depleted to such an extent, I would earnestly suggest to the Minister that the fund in future be made available for extensions which the voluntary hospitals require.

I agree with Deputy Healy from Cork when he implied that in Cork, at all events, the voluntary hospitals for a generation past had given great service to the public with no grants at all available to them. I heard the matron of one hospital run by a community in Cork say, during the last 12 months, that had they been paid for all patients who went through their institution down the years they would be in a position to-day to carry out all the extensions they require. Considering the service they gave to the public in the past, their applications should be sympathetically considered whenever they do make applications for necessary extensions. It would obviate the need for the building of further hospitals.

We all know very well that sanatoria have become redundant, and they can be utilised as general hospitals at a later date. It would be more judicious, more prudent, and more economic to extend the present hospitalisation system in the voluntary and county hospitals, where the administrative units are already there. It could be done at a fraction of the cost required to meet the erection of regional hospitals, considering present day costs.

Mention has been made of bed accommodation by several Deputies, including Deputy Healy. It is one of the very unpleasant features met by members of local authorities who are responsible for the working of the Act. I pay tribute to these men. Membership is no sinecure and the work is not easy. The Health Act imposes very serious obligations on our public men. Only those who have the objective view of serving the public will be enticed on to local authorities. These men are conversant with the administration of the Health Act and with the needs of the sick. Nobody is more competent to give factual opinions and factual advice on the services. If the Minister at any time comes to consider changes in the health services, there is nobody more competent to give expressions of opinion, based on experience, than men who sit on the boards of public authorities.

For a number of years I have been interested in the schools medical service. It could provide a very comprehensive and very effective scheme, but, unfortunately, owing to inadequacies of staff in our county health authorities, the scheme has only just been scratched. I submit to the Minister that it could be made a very excellent scheme if it were operated through the local dispensary doctors. The dispensary doctor lives among the people among whom he practices. He knows the medical history of each family, and he is aware of cases where there is a predisposition to disease. In treating the children of his area in the schools, he will be acquiring a knowledge which will be useful to him afterwards. He will be personally interested in the welfare of these children because of his knowledge of their families. Operated by the dispensary doctors, in conjunction with the county medical officers, it would be an excellent scheme and, operated in this manner, it would entail no further cost in the administration of the schools medical service than it at present entails.

Reference has been made to the various religious bodies who cater for mentally retarded and physically disabled children. I have in mind the Irish Sisters of Charity who deal with cancer, the French Sisters of Charity of St. Vincent de Paul who deal with female retarded children, and the Brothers of St. John of God who deal with the male side of the population. Nobody but the parents of the children affected can appreciate the work which these communities do. I am quite familiar with the institution run in my native town of Glanmire. It is a revelation to go into these institutions and see the spirit of devotion, self-sacrifice and loyalty which the Brothers display towards the children. It is heart-warming in this age to find a body of men working with that community spirit, working for no personal reward and no personal recognition whatever, in the service of God and Christianity, providing comforts for these children. The same applies to the Sisters of Charity of St. Vincent de Paul, to the Irish Sisters of Charity and to other bodies that have recently established institutions here.

It is a pity that these institutions are handicapped for space. Most of them require extensions and they should get priority. I saw a communication from the Minister for Health which was quoted in the newspapers a couple of days ago. He will not make a decision on a regional hospital for Cork until 1961, and I am glad of that. It will give him time during the interval to make a factual appraisal of the whole problem of hospital accommodation in Cork. However, during the interval, bed accommodation must be provided for those people who need it and sympathetic consideration should be given to the voluntary hospitals who have made application for that purpose. In their hospitals they could provide all the bed accommodation which is required in Cork, both for the city and county.

The motion tabled by the members of the Labour Party is very timely. All the signatories to the motion are men who have experience on local authorities. They are in a position to speak with conviction from the experience they have gained through the administration of the Health Act in recent years. There is no doubt that an Act of that kind, so comprehensive in its nature, is bound to have many complications. These have come to light since the Act was first introduced. Personally, I think it is full of complexities and anomalies and I have no doubt that the Minister will bear all these in mind when he comes to consider it. It has given many headaches to the people on local authorities and to the officials who try to administer it as objectively and impartially as they can. It places obligations on them that should not have to be faced by any human being.

Where there is a case of doubt the manager, or his assistant, has to sit in judgment as to whether a man is entitled to free medical service, partially free service, or nothing at all. Because of the exacting nature of the details that must be ascertained before decisions are given, the administration of the whole law is very costly. At present, the Act as it is does not measure up to expectations. It does not even measure up to the national health services to which holders of national health cards were entitled in the past. I dislike the Act because of its degrading clauses and because of its tendency to undermine the pride and independence of our people. I hope the Minister will consider this matter and realise that a time has come when there should be a reappraisal of the administration of the whole Act and when we should get rid of those obnoxious clauses so detrimental to the moral and national character of our people.

Minister for Health (Mr. MacEntee)

It would not be right for me to conclude this debate without saying how much I appreciate the manner in which the discussion has been carried on. All the Deputies who spoke certainly spoke with a great sense of the value of the work which has been done by the Department of Health under—pace, Deputy Manley—the Acts of 1947 and 1953. They also spoke with a full realisation of the many deficiencies in our health services which we have still to make good.

I am as sensible of the things we have still to do as is any Deputy. But Rome was not built in a day and I have to work within a budget with limited resources at my disposal. I have to be content with what I can do with the means that are available to me. We are working steadily to a programme—a programme initiated with the Hospitals Act, 1933, which dealt with the then rather confused and unsatisfactory position which developed when certain voluntary hospitals quite suddenly found themselves with what were, at that time, enormous funds at their disposal and, I think, really began to vie with one another as to the rapidity and lavishness with which those moneys could be spent.

The Hospitals Act, 1933, put the Hospitals Trust Fund and the Hospitals Commission upon a regular basis and provided us with the machinery whereby the whole hospital needs of the country could be surveyed and a considered plan worked out to fulfil those needs. Great progress was made before the war in 1939. With the war, that progress was rapidly slowed down and, one might say, almost ended; ended, because there was a very heavy reduction in the funds provided through the Hospitals Sweepstakes and, even if that reduction had not taken place, it was ended because the building materials and skills necessary to enable large institutional buildings to be erected were not available either.

Deputy Manley, in the course of his speech, mentioned the position of local authorities in relation to the Hospitals Trust Fund and I should like to say this in regard to it. It is 25 years ago since Dáil Éireann gave local authorities the right to share in that fund. This right rests on precisely the same foundation as the right of the voluntary hospitals to share in the Hospitals Trust Fund. Both rights derive from the legislation of this House. One right is no more sacrosanct than the other. No sweepstakes could have been organised here and no sweepstake was organised here without legislative authority. The Oireachtas which gave that authority has a right to extend it and to extend the benefits derived from that authority to whatsoever section of the people of this State it may consider just and right so to do. Therefore, I hope that this attempt to make it appear that the Parliament of this country has inflicted an injustice upon certain voluntary institutions will not be condoned or supported by any public man. I am perfectly certain that if Deputy Manley had been as aware of these facts as I, who lived through them am, he would share my views, too.

There were one or two minor matters of which, perhaps, I might dispose, since they have been raised, in the brief time that remains to me this evening and reserve to another occasion the fuller and more considered reply which I wish to make to the major points raised. Deputy O'Sullivan made a passing reference, a very discreet and proper reference, to the delay which has taken place in publishing the report of the Mallow inquiry. We have now received the bulk of the notes which have been transcribed and which were ready for certification by the stenographer who was on his honeymoon and expected to return about the week-end. That will complete the dossier of the case which will be available to the inspector who will make his report in due course. I am as sensible as Deputy O'Sullivan—and I am sure, as every person interested in this case is also—of the anxiety and worry which the delay has occasioned to those immediately involved in the inquiry. I can assure them and the House that certainly the delay did not arise from any cause which was within our control.

I shall bear in mind a request which Deputy O'Sullivan made to me to examine the possibility of extending to polio sufferers who are civil servants the same facilities as are available to those affected by tuberculosis. There is a difference, which the Deputy himself recognised. In view of his request to me and the helpfulness of this debate generally, I shall have that point re-examined.

With what Deputy Healy said in regard to the necessity for making provision for the old people I am in general agreement—so is the Department, so was my predecessor, so was his predecessor, and so was his predecessor before that, Deputy Dr. Noel Browne. It is a matter which has engaged the attention of the Department for nine or ten years and quite a considerable sum of money has been expended, in attempts to relieve the situation. Again, however, we can only work out our programme with due regard to the resources which we have in hand.

Deputy Dr. Browne, in the course of his speech, raised a number of questions, some of which touched upon fundamental principles. I would not propose to open my reply on these points this evening. With some of what Deputy Browne said I heartily agree. I agree, for instance, with his view that we should try to make our people sensible of the correlation that seems to exist between lung cancer and smoking but one can do, perhaps, as much harm by being over-emphatic in a matter of that sort as by understating it. What we have to try to do is to preseve a balance between advice which will operate to make people think and meditate, and what may be described as high pressure propaganda which would perhaps make them cancer-conscious and engender a neurosis in regard to it.

It was one of the real difficulties at the beginning, when we were trying to tackle the tuberculosis problem, that people got a belief that they were suffering from tuberculosis and when they got that belief they tried to conceal the fact from themselves and from their neighbours. The earlier propaganda in that field, instead of having a beneficial effect, may have had rather the contrary effect.

We are, as I may say again, and as I mentioned in reply to questions by Deputy Dr. Browne the other day, considering the matter in the Department, with a view to the preparation of leaflets which may be distributed. However, so much interest has been directed to this question that many people are aware of the danger of excessive tobacco smoking, whether in the form of cigarettes or pipes, and when they are sensible to that fact you have to allow their own good judgment and good sense to let them draw the moral and, if possible, try to change their habits.

Deputy Moloney had some quite useful things to say regarding the dissatisfaction about the distribution and issue of health cards. He also pointed out that in no two counties—and that is our experience—is there precisely the same system. The real fact to remember here is that, whereas you will hear complaints about some people getting cards and others not getting cards, if the type of investigation which was contemplated when the Act was passed was carried out, that investigation would show that, no matter how alike, no matter how similar, two cases may look to the outsider, when both are examined closely, differences will appear, and those differences may be sufficiently substantial in one case not to warrant the issue of a health card and to warrant it in the case of another applicant.

The whole basis of the compilation of the general medical services register is this. We could not deal with this problem through a highly centralised organisation, since no two counties in Ireland are alike, no two towns are alike, and the resources of towns and counties are not alike. First of all, therefore, we put the responsibility for issuing the cards on the local authority because it is aware of the local conditions, the financial conditions of the applicants for health cards and the financial condition of the community as a whole—which, to some extent, has to determine the liberality with which health cards can be issued.

Mr. Corish

If I might interrupt the Minister, that is one of the difficulties at the present time. The Minister replied to a Parliamentary Question recently, showing the percentage of population covered by medical service cards. I am afraid many of the local authorities now are having regard to that percentage, or the average percentage in the State as a whole.

Mr. MacEntee

That shows how much harm may be done by giving the information which is asked for sometimes in this House.

Mr. Corish

I did not ask the question.

Mr. MacEntee

It has been said by one Deputy in the course of the debate that this is a very flexible system. It was intended to be a very flexible system; it had to be a very flexible system, because of the differences which exist in conditions throughout the country. Those differences exist as between applicants and as between counties. I do not think we could devise a better system. I made inquiries some time ago as to how the work of the local authorities was done and I found it was done according to the good judgement——

Mr. Kyne

What was that?

Mr. MacEntee

The good judgment of the——

Mr. Kyne

Of the county manager.

Mr. MacEntee

Well, of the local authority.

Mr. Kyne

On instructions from the Minister.

Mr. MacEntee

I do not think I have given instructions.

Mr. Kyne

Or the Minister's predecessors?

Mr. MacEntee

Or my predecessors —I do not think so at all.

Mr. Kyne

I am sorry.

Mr. MacEntee

In so far as any instructions were given at any time, the effect may have been to confer a greater degree of elasticity. I do not think anything was imposed on the local authorities, except to tell them they had to have regard——

Mr. Kyne

Such as £4 10s. for rural areas.

An Leas-Cheann Comhairle

The Minister is concluding.

Mr. Kyne

I know; I am just intervening. Such as £4 10s. for rural areas, £5 for urban areas and £5 10s. for other areas. Is the Minister denying that?

Mr. MacEntee

I have no recollection of it.

Mr. Kyne

Not by the Minister, not by Deputy MacEntee, but by his predecessor.

Mr. MacEntee

Or even an earlier predecessor, perhaps?

Mr. Kyne

By a Fine Gael Minister, if you like.

Mr. MacEntee

Now, we have not been debating this issue in a partisan way.

Mr. Kyne

I know that—no Party politics.

Mr. MacEntee

We have had a very helpful discussion. If any such instructions were issued by my predecessor in office, I am carrying the responsibility now, and if I have not changed the position I have not done so because I thought it was a well-advised act on his part.

Mr. Kyne

I am sorry, a Leas-Cheann Comhairle. I did not intend to interrupt.

Mr. MacEntee

I was dealing with the question of the health service cards, but I would not be able to finish on that point this evening.

Progress reported; Committee to sit again.

The Dáil adjourned at 10.30 p.m. until 3 p.m. on Wednesday, 30th April, 1958.