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Dáil Éireann debate -
Tuesday, 6 May 1958

Vol. 167 No. 10

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.)

It is rather difficult in a debate on an Estimate which covers such wide ground and upon which so many matters of detail have been raised to make what would be described, perhaps, as a composed and shapely reply. So I can only take the principal points seriatim giving, as I think I should, precedence to the points raised by my predecessor, Deputy Tom O'Higgins. I should like to say here that I found his speech very helpful and gratifying because, quite clearly, he appreciates the difficulties under which a Minister for Health has to labour in present circumstances.

In the course of his speech Deputy O'Higgins inquired what progress had been made in the provision of a rehabilitation service. The position is that an interim report has been received from the National Organisation for Rehabilitation which Deputy O'Higgins, as Minister for Health, set up in November, 1955. This report contained a considerable number of recommendations in relation to various aspects of a rehabilitation service. The recommendations, which affect a number of Government Departments, have been circulated to those concerned and at the same time they are being examined in the Department of Health. We hope that a submission— which is in preparation—on the report will be available for my consideration within the next few weeks.

Deputy O'Higgins referred to another matter and perhaps I should quote, or at least paraphrase, his remarks. He said it had come to his notice that in some cases doctors on the staff of voluntary hospitals are seeking to charge fees in respect of the treatment of patients in the public wards of their hospitals and in that connection he said this was a practice which he completely condemned. He said: "I should like to express my complete condemnation of any person who seeks to impose any such charge". Of course, the Deputy has expressed my attitude towards that practice. It is perhaps difficult to see what we can do to curb it but, if necessary, legislation will not be ruled out because it would be quite wrong to permit the clear intention of the Legislature to be defected by those who have entered into an agreement with the State to provide these medical services free of charge in public wards. I do not want to say any more than that, but I certainly do not wish any of those who may be engaging in this practice to feel that they are likely to get away with it.

Deputy O'Higgins also raised the question of providing for those who were in the lower income group a choice of doctor. The matter was mentioned also, I think, by Deputy Coburn, by Deputy Loughman and others. I suppose it would be a desirable thing, if it could be done without any undue administrative difficulty or greatly increased expense, to provide those who are in the lower income group with the same choice in regard to their general practitioner as is provided for them under the maternity scheme. But examinations which have been made in the Department— a preliminary examination under Dr. Ryan and further examinations when Deputy O'Higgins was Minister for Health—have indicated that there are many difficulties involved.

The first difficulty is that it is highly doubtful whether it would be possible to provide this choice of doctor for the lower income group outside the larger centres of population so that we should be put—not that I would regard it as being of any very great moment—in a position in which we would have, perhaps, some very eminent people coming along and telling us how the Government were discriminating between town and country. If it were possible to provide a general practitioner panel service for the larger centres of population and if we found ourselves unable to do that in the rural areas we would probably be charged by some people in high places with discriminating between town and country. Enough attempts have been made to create—so to speak—bad blood between the inhabitants of urban and rural districts for me, at any rate, not to give further cause for complaint in that respect.

Apart from this there would be the question of expense, and this, in regard to the schemes which were examined when Deputy O'Higgins was Minister, would be quite considerable. I am informed that a modified proposal, which he suggested should be examined, would not be so expensive but it is doubtful whether, in our present circumstances, we could undertake to provide this additional right for those in the lower income group. However, I shall ask that the matter be examined further and it may, perhaps, be possible to do something. Candidly, I do not think it will.

Deputy O'Higgins also urged that there should not be undue caution— that is not precisely what he said: he put it rather the other way and urged that there was a danger that there might be undue caution in curtailing hospital building—because of the condition of the Hospitals Trust Fund. I do not think any Minister for Health, continually bombarded as he is with requests for money to finance the continuance of hospital programmes, would be permitted to be unduly cautious, but I am concerned, and it is my first concern, to see that the Hospitals Trust Fund is put on a fairly substantial basis again, because I do not think that we can, in the circumstances of the world around us, afford to build up heavy, uncovered commitments in respect of building contracts. I would certainly like to be sure that if any project is started it will have a reasonable chance of being carried through to completion even if the worst should happen and we found ourselves in such a position that the income which the Hospitals Trust Fund derives from sweepstakes was suddenly reduced or perhaps cut off entirely.

Deputy Dr. Browne criticised me very severely for the policy which I have adopted in regard to vaccination against poliomyelitis. He held that it was a retrograde step to expect parents —this was the burden of his criticism— to pay for the vaccinating of their children against poliomyelitis, even if they could afford to do so. I do not think there is anything retrograde in asking a parent to shoulder his parental responsibilities, when he is in a financial position to undertake that obligation. On the contrary, it would be, in my view, a grave and indeed unjustifiable retrogression to permit a parent who can well afford to look after the health of his children to unload his obligations and impose them on his neighbours.

Deputy Dr. Browne painted a harrowing picture of the distressing condition of children who have been stricken by this terrible disease. None of us who has any knowledge of the disease will attempt to minimise the suffering of the afflicted or the anguish of their parents; but we are not arguing about the nature of the disease or about its terrible characteristics. There is no controversy about that. We are in agreement about it and it is not an issue. What is in issue is whether it is just and equitable to use the limited resources at our disposal to help those who are in the greatest need of assistance and to expect of others, whose circumstances enable them to do so, that they should look after themselves. That, I think, is the issue, and the only issue, between Deputy Dr. Browne and myself.

The weakness of the case he has made is proven by the devices to which he has resorted in order to support it. First, we had this high-pitched appeal to the emotions. Then we were told that we were condemning children to death, or at least to be maimed and crippled for life—thousands and thousands of them, until hyperbole could soar no further. Then, the case was cited of a white-collar worker in the middle income group with a family of 12 children. A graphic picture was painted of his struggle to determine whether he would have only six of them, or none of them, vaccinated. I should like very much to have further particulars of this white-collar worker whose marriage has been so fruitful and so blest. One would like to know, for instance, the ages of his eldest and his youngest child. It would be interesting to know also what his occupation is, and whether he is insured. All this would be helpful and I should be glad to have the information and other specific particulars of the financial and general circumstances of the gentleman whom Deputy Dr. Browne has in mind. We can then see if there is any need in the particular circumstances to make special provision to meet his, and similar cases.

As I have said, we are providing vaccination against poliomyelitis free for the children over six months and under ten years in the lower income group. If our means permitted it, I should prefer to enlarge the group not by relating its range to the economic circumstances, but by relating it to the ages of the children concerned. In any event, most parents outside the lower income group should be able to carry and should, in my view, carry, their parental responsibilities. God forbid that any act of mine should result in any child being stricken with the disease. I would not carry such a responsibility lightly; but I do not think that we should carry paternalism so far as to relieve parents, who can carry their responsibilities, of the obligations which God and nature have imposed upon them in relation to their children.

The children belong to them. They are theirs to nurse and care for and, so far as the care of the children is concerned, if they are not in a position to provide it, if they cannot afford to look after their children, then the community comes generously to their aid. But if the parents are in a position to provide for the physical care of their children, why should the community be asked to provide it? Even if it does involve the parents in some little self-deprivation for the sake of the children why should they not accept it as duty? It is a very easy declension from providing services for others, and caring and rearing for others, to arrogating to oneself a proprietary right in regard to those for whom we care. And that is where, I think, unnecessary and intrusive eleemosynary action on the part of the State would eventually lead us.

I have never accepted the position in relation to those things which, as I have said, parents or other people are bound in their natural duty to do, that they are entitled as of right, even if their circumstances do not justify it, to demand that others should carry the burden for them. If we were to enlarge this scheme in the way Deputy Dr. Browne suggested, and if everybody covered by it were to take advantage of it, it would cost the State the better part of £500,000—that is, if everybody were to take advantage of it—and that £500,000 could be found, in general, only by imposing additional burdens upon the lower income group and the middle income group for whom Deputy Dr. Browne is so concerned. The burden would be passed on to these groups in order to relieve those who should rightfully carry it of the obligation of doing so.

Deputy Dr. Browne also criticised the voluntary health insurance scheme. There may be aspects of that scheme which may perhaps be criticised; I do not know. I am only assuming that, like every other thing of man's devisiting, it has its imperfections. However, there is no substance in a criticism which takes the worst possible case, enlarges on it and then says: "That is the sort of thing you are doing by providing this voluntary health insurance scheme!" The main criticism by Deputy Dr. Browne of the scheme were (1) that the scheme is expensive; (2) that it is not sufficiently comprehensive and is unlikely ever to cover more than 20 per cent. of all those not eligible for free or subsidised health services and (3) that the correct basic fundamental principle upon which a health service should be based is that there should be a comprehensive no-means-test scheme financed by taxation. I have already stated my position in regard to the last point and perhaps I should go on to consider the others.

We have to remember that, as conceived, the Voluntary Health Insurance Board and the schemes it operates are expected to be self-supporting and self financed. The State has provided the board with certain money to enable it to commence its operations. I think the general theory behind it is that the scheme will be operated for the mutual benefit of those who are organised within it and that they, themselves, will provide the income to finance the operation of the board and to finance the benefits which the members are expected to derive from it. Outside that, the Voluntary Health insurance Board conducts schemes which are non-profit making. Any surplus which may accrue from year to year or from time to time as a result of the board's operations will be given back to the policy holders, the subscribers to the scheme, in the form of enhanced and improved benefits.

In the example which he cited, in criticism of the operations of the board, Deputy Dr. Browne quoted the highest possible rates chargeable, that is, the rates chargeable to a married couple with four or more children joining the scheme as individual subscribers. First of all, let me say that rather lower rates are chargeable to people with fewer children. Secondly, even still lower rates are chargeable to those who join the scheme not as individual subscribers but as members of a group.

The examples mentioned by Deputy Dr. Browne are to be found on page 7 of the board's brochure. There, it will be found that a married couple with four or more children can participate in scheme "A" for an annual premium of £13 10s. 0d., in scheme "B" for an annual premium of £17 10s. 0d. and in scheme "C" for an annual premium of £23 10s. 0d. Therefore in that particular group, at least six individuals are covered by the premium paid. On that basis, if we divide the £13 10s. 0d. payable under scheme "A" by six we shall see that it comes to a payment of £2 5s. 0d. in respect of each person in that family. If we divide the £17 10s. 0d. payable under scheme "B" by six we shall see that it comes to a payment of £2 18s. 4d. per person in that family. In the case of the six persons covered by scheme "C", in respect of whom a total payment of £23 10s. 0d. would be asked, the payment amounts to £3 18s. 4d. per person. Contrast those figures with the £5 10s. 0d. per person which Deputy Dr. Browne mentioned in his criticism. I think it will be found that, on the whole—and taking into consideration the benefits given under the voluntary health insurance scheme—members of the scheme are getting what is reasonably fair value. I have not mentioned anything about the reduction of about 10 per cent., on the premiums which would be secured by a member of a group insuring his family under the scheme or anything about the rebate in income-tax which is obtainable on the premiums, because the amount of the rebate would vary with the circumstances of the subscriber.

The second criticism which Deputy Dr. Browne launched against the scheme is that subscribers are not covered for appliances, dental treatment, maternity and general practitioner care. The fact is that cover is given for appliances in respect of two-thirds of the cost over £2 10s. 0d. up to a maximum of £50 under scheme "A", £60 under scheme "B" and £75 under scheme "C". I think that that is quite substantial cover having regard, again, to the circumstances of the individuals who are expected to avail of the scheme.

Deputy Dr. Browne also criticised the scheme because there is no provision in it for dental benefits. No recommendation to include dental benefits in their schemes was received from the Voluntary Health Insurance Board. The arguments against including dental benefits in a scheme of this sort are set out in the report of the advisory body which considered the practicability of setting up a scheme of voluntary health insurance. Briefly they are: firstly, that the cost of dental treatment is not normally excessive. Secondly, since such treatment as a general rule can be postponed, any scheme of dental insurance would be presented with many claims arising out of postponed treatment. Therefore, such an insurance is not a practicable proposition.

As regards the insurance against maternity costs, the board made no recommendation for the inclusion of cover under this head. Of course, the question was considered at lenght, and it is true that the advisory body did consider and recommend, even though the costs of confinement were predictable as to time and amount, the inclusion of some provision to meet such costs in the scheme of voluntary insurance. As I have said, however, the board did not accept this. Any person joining the voluntary insurance scheme, who is eligible for institutional and specialist services under Section 15 of the Health Act, 1953, is entitled to all the benefits of the maternity services, if the person so desires, which are provided under the Health Acts.

As to the other point of criticism that the scheme does not provide for general practitioner care, as a rule, this is, and generally should be, met out of income.

The next type of criticism Deputy Dr. Browne made was this. He suggested that in time the number of people who would be covered by the scheme would settle down at from 80,000 to 100,000, and that against this there are 300,000 or 400,000 people who would be eligible to join the scheme, to whom it might be advantageous to join the scheme but who would remain outside it. How many of the people who are not covered by the present health services will eventually join the scheme is anybody's guess. So far, 50,000 persons have joined it within the short period the scheme has been in operation. Scarcely a day passes but I receive one or two letters from people down the country asking me how they may join the scheme. So that, as the knowledge of it is becoming more widespread, people are becoming more anxious to know what it is all about; and presumably when they are told what it is all about, they will become, in due time, subscribers. The main justification for the scheme is that it provides a service which can be availed of by those who are in a position to take it, and who are not covered in any other way. They are free to join or not to join, as they so desire, provided, of course, that their general physical condition and health is not such as would impose an undue burden upon the scheme.

Deputy Kyne raised a great number of points. Many of them were referred to by other Deputies. If I fail to mention by name any of the Deputies who brought these matters to my attention, I can assure them I listened to what they had to say, even though I shall just have to deal with the points as they were mentioned by the speakers who raised them in the first instance. Deputy Kyne suggested that appeal machinery should be provided under the Health Acts. That has been considered from time to time in the Department. Indeed, the Health Act of 1947 did grant a right of appeal to the Minister by persons aggrieved by decisions of health authorities in relation to the granting of infectious diseases maintenance allowances.

That right subsisted for a period of six years. During that period, about 1,700 appeals were considered. The vast majority of them, however, were refused. They were not sustainable appeals. In view of that, the 1953 Act abolished that right of appeal. I do not see that, so far, a substantial case has been made for setting up an appeal board to consider cases where persons have been refused the grant of a medical card. I fear, having regard to the great number of persons involved, that the difficulty of assessing the means and general circumstances in every case would make the work of an appeal board exceedingly onerous, exceedingly difficult and exceedingly expensive.

Of course, the manager has the same difficulty.

Yes, but he is dealing with fewer people. He is in a position in which he must balance the scales fairly between the applicants, on the one hand, and his local authority, on the other.

Theoretically, he decides who gets the medical service.

In fact, he is the appeal tribunal in relation to most of the administration of the Health Acts in his local authority area. In most cases, the home assistance officer makes the original assessment of means. It then goes to the manager, who considers it. It may be that, if persons are turned down, they can have an appeal made to the manager on their behalf and he will reconsider it. There is already in fact a sort of appeal tribunal in existence in every local authority area.

Would the manager not be reluctant to reverse his original decision?

I do not know. If the manager feels he has not done justice in the first instance, I should be very surprised to learn that he would be reluctant to reverse his decision. After all, there is no guarantee that an appeal officer, who would have to consider three parties—the State, the local authority and the applicant— might not have to look at it very much more objectively than a county manager might feel himself able to do.

Deputy Kyne also raised—and so did Deputy O'Higgins—the question of providing dental services for the middle income group and their children. As the House knows, dental services are being provided at present under the Health Act of 1953, but these are limited to the lower income group, school children and children attending child welfare clinics. Section 21, dealing with dental services for the middle income group, was brought into force in January, 1955, but regulations to give effect to the provisions were not made. As I mentioned in my opening statement, the cost is one of the reasons—a major reason—why we are not in a position to expand the existing dental services. In addition to that, it is doubtful whether the requisite personnel would be available to man the services, even if we were in a position to pay for them.

Deputy Kyne, Deputy Brennan, Deputy Loughman, Deputy Healy and a number of others referred to the position of old people in district mental hospitals. It is true that there is a great number of senile, old people in these hospitals and we would very much like to see them provided for elsewhere. In fact, in 1956, my predecessor directed a circular to issue recommending the establishment of psychiatric consultation services which would be made available to authorised medical officers in the case of old people who might be recommended for admission to a mental hospital. In this circular, it was strongly recommended that old people should not be brought to a district mental hospital without having first been seen in consultation by the hospital psychiatrist. In certain areas we have already been able to take steps to discharge or to transfer from mental hospital to alternative accommodation suitable people who no longer need constant psychiatric attention.

Deputy Kyne also mentioned the question of the revision of the dispensary districts in the Waterford Board of Public Assistance area. I am glad to say that the Order revising the present Waterford City area dispensary districts to form three dispensary districts, Waterford No. 1, Waterford No. 2 and Waterford No. 3, has been signed and has been sent to the local authority.

Deputy Kyne also pressed that accommodation should be made available for low-grade mental defectives and suggested that this accommodation might be provided in mental hospitals, if possible. It is rather unusual to have a plea made to provide low-grade mental defectives with accommodation in mental hospitals. Persons in that class require even greater attention and a different type of care from that which is usually provided in mental hospitals and, indeed, most mental hospitals are not in a position to give the particular specialised care which low-grade defectives require. Deputy Kyne, Deputy O'Higgins, Deputy Brennan, Deputy Faulkner and Deputy Desmond all pressed that accommodation for mentally handicapped children should be increased. I can say that the needs of these patients are constantly before the Department and I think it can be said that a great deal has been done for them in recent years. Since 1948, in fact, the accommodation has been almost doubled.

Unfortunately, I should say it has been found that accommodation provided for other purpose which becomes redundant has not in general been suitable for these patients, especially for the low-grades for whom, again, as I have said, the need for more accommodation is particularly pressing. Another difficulty is that there is a lack of properly trained staff to look after these children. We have, however, within the last 12 months or so, given some encouragement to one or two of the religious orders who undertake this charitable work to go ahead with their plans even in a rather restricted way. The difficulty is, of course, that we simply have not got the money to enable them to complete the proposals as they were originally envisaged.

With regard to hospitals in County Waterford, Deputy Kyne suggested that there should be a conference between the county manager, the board of assistance and the medical officers in Waterford at the instance of the Department to try to get agreement upon a hospital programme for Waterford in the next 20 years. Our experience since 1933 has shown us that, in many instances at any rate, attempts like this at long-term planning do not eventuate in anything tangible except, possibly, an unwise expenditure of money.

We have already suggested to the three interested local authorities in the Waterford area, the corporation, the county council and the board of assistance, that the 300 bed hospital at Ardkeen should be taken over and used as a county hospital in lieu of the old former workhouse. That proposal has been before these authorities for well over a year, but it has been held up by some difference of opinion between them as to the method of allocating cost. When we see that such an important project as this has been held up on that ground, it is difficult to see what advance could be made at a conference such as Deputy Kyne suggested. If the proposals which have been made to the health authorities in Waterford were to be approved, then I think the needs of the Waterford area for general hospital accommodation could certainly be adequately provided for over the next 20 years.

With regard to the suggestion that we should permit the Waterford Corporation to pay a larger contribution to the National Society for the Prevention of Cruelty to Children, all I can say there is that the work which that society undertakes is, perhaps, more properly related to the Department of Justice than it is to that of Health and my Vote is already sufficiently large and I think the local authorities feel that the burdens of the health services are already sufficiently great to make me very circumspect, very reluctant to agree to local authorities accepting any responsibilities which are not clearly within their ambit. If the society in Waterford wishes to secure any further moneys or there is any question of an increased subvention from State funds, I think it will have to address its request to the Minister for Justice.

Deputy Kyne also raised the question of the charges made for persons availing of institutional services. He said that where a person in the middle income group visits a hospital there are very few instances in which the charge made by the health authorities is less than 10/- a day and that what was originally intended as a maximum charge has become a minimum charge. He also argued that the charge in the case of children should be less than for adults. As to the statement that the 10/- has become a minimum and not a maximum as originally provided, I have made very exhaustive inquiries and I am quite satisfied there is no foundation in the ultimate for it.

Different health authorities have different ways of approaching this problem. Some have the practice of billing the person with the maximum charge of 10/- a day and leave it to him to prove that that should be considerably reduced. Others have adopted a different procedure. It is a matter of local administrative convenience which does not prejudice any person in the end. It certainly does not mean that anyone is called upon to pay more than he properly should. Every local authority has been questioned, even those who administer this scheme on a most conservative basis and in every case the majority—and in some cases the vast majority—of the persons concerned pay very much less than 10/- a day.

I dealt with some of the points made by Deputy Brennan, in the course of my comments on the points raised by Deputy Kyne. One point to which I referred, and which I might amplify a little, was the plea that we should provide more beds for mental defectives. The number of beds available in prewar days was about 1,150 and the number provided since the war totals about 1,320. Some schemes which will provide another 240 beds are nearing completion. One of the major schemes to be approved, even since the period of financial stringency came to a head, is stage two of the scheme at Cregg House, Sligo, which is administered by La Sagesse Order. Details of this scheme are not offically settled. The costs will be considerable and the number of beds will exceed 100.

It is also possible that a further section of the scheme for a mental defective institution at Delvin, County Westmeath, will be allowed to commence. The problem here, as in the case of all other building projects we have in view, is that we have not got the money. In the case of La Sagesse Order, there are very special circumstances. The Order was invited here on a very definite undertaking. I agreed to allow the building to proceed because I felt that we could not any longer fail to fulfil, even partially, our commitments in that regard. Apart from this, there is always the primary factor that we need the additional beds for mentally defective children.

Deputy Brennan also suggested, dealing with the general position in mental hospitals, that there should be facilities for segregating volunatry patients from chronic cases. There is no doubt that there ought to be facilities for segregation in our district mental hospitals, not so much on the basis suggested by Deputy Brennan as on the basis of degree and classification of mental illnesses or disorder. Unfortunately, a great number of our mental hospitals lack proper facilities for segregating their patients in this manner, due to overcrowding, inadequate planning, inadequate and unsuitable buildings and, most important of all, the lack of a proper admission unit where patients can be examined, treated and classified following reception.

We have made some progress in that matter recently. Monaghan County Council have at long last accepted the proposal regarding what was originally built as a treatment unit for the mental hospital, which was then converted into a tuberculosis institution, and which has now become redundant. At last they have agreed —and I am grateful to them for it—to allow this building to revert to the purpose for which it was constructed originally, so that, in the case of the mental hospital administered by the Joint Board for Monaghan and Cavan, they will at last have their admission unit.

I wish we could do that for the other mental hospitals in the country and it will be one of my aims to do so wherever buildings become redundant and are suitable and are not required for other pressing purposes. It is difficult to say which purposes are the more pressing, where there are so many unfulfilled demands and crying needs to be met. Wherever a suitable building becomes redundant, I should certainly like, if it could conveniently be adapted, to utilise it as an admission and observation unit in association with the mental hospital.

Deputy Brennan also advocated greater subventions to private mental institutions. All private mental institutions approved under the Health Act of 1953 are eligible to participate in subventions for patients suffering from mental diseases. Health authorities may send patients to those institutions and pay the approved capitation rate, six guineas a week, which, except for the absence of the doctor's supplement, is the same as for the voluntary general hospitals. This capitation rate is payable by the health authorities only for the first three months of each eligible patient's stay in the hospital; thereafter, the rate is three guineas a week, which approximates to the national average cost of maintaining and treating a patient in a district mental hospital.

The health authorities are obliged to make a contribution to eligible persons entering those private institutions on their own arrangements under Section 25 of the Health Act, in additions to those who enter in the ordinary way as Section 15 ceases. The contribution in those cases, as perhaps the House will recollect, is arrived at by deducting 10/- a day from the full appropriate rates. The contribution payable in the Section 25 cases is £2 16s. for the first three months and then it ceases.

The difficulty about all these private mental homes and institutions for long-stay patients is that, of course, the local authority could not continue to pay indefinitely a capitation rate which is greater than the actual cost which a local authority would have to bear if the patient were in its own institution.

Deputy Brennan, I think Deputy Esmonde, and other Deputies, raised the question of dispensary midwives. Undoubtedly a review did take place in 1955 and it disclosed the fact that no fewer than half of the permanent dispensary midwives were dealing with only ten eligible cases a year or less. In fact, the average fee payable to half of the permanent midwives was £40 per case. I think it will be seen that we could not allow the position to continue and that it will have to be resolved in a way that will ensure that the local authorities, and the State, get an adequate return for the money paid out by them. No midwife will be harshly treated. No definite decision has been taken to dispense with the services of any permament midwife yet, but undoubtedly some will be compelled to retire although we shall do everything possible, and the local authorities will be asked to do everything possible, to place those who are suitable in other posts.

Deputy Brennan also raised the question of tubercular patients in the Civil Service. It is not correct to say that if a condidate puts on his form that he is a discharged tubercular patient he will find himself debarred from a post although he has a clean bill of health. The position is that the candidate undergoes a medical examination and if the examining doctor is satisfied that there is a reasonable prospect that the candidate will be able to render regular and efficient service in the future he will be certified as medically fit. Naturally when the candidate has been in a sanatorium recently, say within a period of six to 12 months previously, the certifying doctor would in most cases be reluctant to give a qualifying certificate. In such cases, however, the candidate may appeal and he is re-examined by a board of three specialists in tuberculosis, and if the board passes him as fit he is certified for the position. May I say that a number of persons who have suffered from tuberculosis have secured admission to the Civil Service under the procedure which I have outlined? The position with regard to candidates for admission to the Garda Síochána, however, is slightly different because the Garda authorities must bear in mind that the ordinary duties of a Civic Guard call for a better health history than in the case of those admitted to the Civil Service.

Deputy Brennan also raised the very vexed question of the site for the new hospital in County Donegal. That is a very tangled skein and there has been a great deal of chopping and changing. The position is that a hospital is now being built at Dungloe. After opening the Dungloe Hospital, we shall try if we can find a suitable use for the old district hospital, but it cannot be run as a general hospital and it cannot be run as a maternity hospital in association with the tuberculosis unit.

Is this the hospital at Glenties?

I am glad the Minister is there and not I.

As I say, it is a very tangled skein and I do not think the years have made it any easier. The Dungloe hospital is a new, modern hospital built at considerable expense. The Glenties hospital has been there for quite a while, but we cannot have the two running together. We should like to find a use for the Glenties hospital but it will have to be a use which will be economically justifiable. It all depends on the extent to which the Glenties people are prepared to modify their ideas of what they think they should have. We could use the existing building in Glenties as a tuberculosis unit and I think perhaps that would be the best and most suitable use to which to put it and one which would be most advantageous to the hospital services in the county as a whole.

Deputy Moher, in the course of his speech, referred to something which I myself noted with a great deal of concern—an article which appeared in the journal of the Irish Medical Association last month, headed "Ten Fruitful Years". It has really put me in a quandary. In dealing with the Irish Medical Association I do not know whether I am dealing with a professional organisation or a political organisation. I trust I shall be able to feel that this body is concerned purely with the professional side of medicine and not with the political aspects of the health controversy which, I hope, are dead and buried. It does not help a Minister, who has had some responsibility for the promotion of health legislation in this country since 1941, to find that he is accused of having tried to socialise medicine, when the Government and the Oireachtas enacted the Health Act of 1953.

I think, having regards to the fact that the Health Act of 1953 is now accepted as the basis of our health services, has been worked by all Parties in the House and has been approved by the votes of the people in the last general election, it is about time that statements like this ceased to appear in a journal which professes to be concerned with the lofter professional issues.

This is the statement to which Deputy Moher referred and to which I take the greatest exception:—

"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 odedience to its ukase in 1953 was the outcome of the five preceding years of building is a fair and just conclusion."

If I were to approach the problems of the medical profession in this country in that frame of mind, I might say: "Well, all right; you did bring us down in 1953 but we are back. How do you expect us to deal with you now?" I do not propose to do that, but that is the sort of natural reaction which statements of that description— quite unjustified statements—evoke. The Irish Medical Association had as much to do with the defeat of the Government in 1954 as a cuckoo's spit might have had. Rather was it the price of the pint and not the fact that we were proposing to provide better medical services for the people which defeated the Fianna Fáil Government in 1954.

However, it is up to those who control this association and those who are on the councils of the association to bear in mind that they are not in any position to dominate the political life of this country. If they wish to regard their professional organisation as a political weapon to be used against any Government of which I am a member in relation to any of the matters which may come to issue between us, it will be so much the worse for them.

I do not think the Minister should allow himself to be provoked unnecessarily. It was Deputy Moher who raised this.

He raised it, but I trust that those who were responsible for the publication of this article will realise it is a mistake to write in those terms now.

There is enough water under the bridge.

There has been, I agree.

I agree. I am now going to defer to the Deputy's prudent concern. I was very annoyed. I am perfectly certain that if these statements were written when the Deputy was in office, he would have taken the same view. I know that when Deputy O'Higgins was in office as Minister for Health, he had to deal with many of these matters. All of us in that Department have to keep in mind the rightful desires of the professional class, on the one hand, and the needs of the people who are our primary concern on the other. Having said so much, I will take the Deputy's advice and move on.

There were many other matters referred to. Deputy Carty mentioned the overcrowding in the Galway Regional Hospital. Overcrowding is, of course, a relative term. There was genuine overcrowding in the old Central Hospital which was a former workhouse. I do not think that there need be any overcrowding in the Galway Regional Hospital now. We are naturally endeavouring to make the most economic use we possibly can of the space available and we are not in a position to build.

We must provide for those patients who are in the need of hospital accommodation, hospital beds and treatment. We just simply cannot allow ourselves in this matter to be thwarted by an over-liberal and uneconomic use of space. As the matter has been raised in connection with this particular institution I must say that in my opinion there can be a much more rapid turnover of beds there. A survey of the position was made recently. The duration of bed occupancy in some cases was really startling. There were, for instance, last February 106 patients in the hospital who had been there for two months or more. One Patient has been there for six years; another for three and a half years; five for about two years; nine for 18 months; 17 for nine months and the remainder for varying periods up to six months. Twenty-two of these patients were 70 years and over and there were 12 between the ages of 60 and 70 years. That is one of the reasons why there is a shortage of beds in this magnificient hospital in Galway which was erected at considerable expense in order to ensure that the needs of those who genuinely required treatment in an acute hospital should be catered for.

We just cannot allow that position to continue. While there may be some degree of inconvenience imposed upon certain persons, nevertheless, we have to consider the fact that additional beds can be installed in the hospital without any great detriment to the comfort and convenience of the patients. It is the comfort and convenience of the hospital patients which have to be my first concern. I will do nothing, of course, which would make it difficult for members of the staff there to discharges their duties properly and effectively, but we have to have a degree of understanding and a degree of co-operation in these matters which I hope will be forthcoming. There are many other matters which Deputy Carty raised which I will not deal with now but about which I shall write to him.

Deputy Coogan referred to the demolition of the central block of the Galway hospital and wished to know why it was that tenders had not been advertised for it. When a contractor is on the site and if there is something which might be described as ancillary to the works upon which he is engaged but which is not covered by the original contract, it is quite a usual thing that he be requested to undertake this extra work and to give him the contract, provided his price is reasonable. In this case, the old block was demolished at a cost of £5,000.

Deputy Coogan asked what would have been the result if the building had been offered for sale and went on to suggest that, instead of the local authority losing £5,000, they would have gained £5,000. That is a very doubtful proposition.

Offer it like the mansions.

It was not a mansion. I have seen it and the last thing I would describe it as is a mansion. It looked like what it was originally, part of an old workhouse.

There were marble mantelpieces there.

There were no marble or Bossi mantelpieces and no mahogany doors there—not even pitch-pine flooring. It was just an ugly stone building which must have cost a great deal even to demolish. I do not think the Galway people lost anything in money and they certainly lost nothing in convenience and expedition when they asked the contractor who was on the works and built the hospital to knock this whole building down.

Incidentally, that contractor did not knock it down. It was another contractor.

No, it was Messrs. Stewart.

I heard it was a sub-contractor.

Yes; it may have been a sub-contractor. That is very often done, but the price to the hospital authority was based on the original contractor's schedule of prices.

Did the Minister refers to rehabilitation?

Then I can read it in the Official Report.

I mentioned that we had received the report, that it had been circulated to the other Departments concerned, that it was now being reviewed and that the submissions would be coming to me in due course.

Vote put and agreed to.