I received this morning by post a book about the health services of Ireland, which I am very glad to see. In the first instance, I know the official who wrote it and I have a great regard for his ability and for his knowledge of the health services. I think I recognise in him the person who was the secretary of the National Health Council for quite a considerable period before his present promotion. I have not had time to read the book yet but I feel it is a good book. It may help considerably to clear up the muddle that exists generally in the minds of the people in relation to our health services.
I make no apology for criticising the health services. I think every Deputy knows I personally felt that the scheme would be an almost impossible one to administer. I frequently stated in this House in the long discussions we had on health that I felt it would end in those who are most deserving standing at the end of the queue, while others, who were not so deserving, got the benefits. Be that as it may, I think there is practically no section of the community that is satisfied with our existing health services. I want to be fair. The Minister was not Minister for Health when this legislation which is responsible for the administration that has to be carried out today was enacted. I described it before in this House as being a public futility and I do so again.
However, it is up to all of us to do the best we can to see that they are properly administered and to offer what advice we consider desirable to the Minister. I should like the Minister to give some indication as to who is entitled to a health card. That is one of the outstanding problems in the health services. One of the most frequent requests I get in my constituency — it is not a frightfully poor constituency compared with other constituencies — is from people who want to know if I can get them a health card. I am absolutely certain that 90 per cent. of the people who write to me on that subject would have been, under the old service, known as the dispensary services which, I believe, served this country well for a great number of years, entitled to free medical services. Nowadays they find they have to pay considerable sums for themselves and their dependents.
I want to cite a case for the Minister that came to my notice the other day. I know of a man who is earning £8 a week and who occasionally with over-time earned up to £9 a week. He had six or seven children and a delicate wife. He could not secure a health card. His wife had to go to hospital and spend an extended period there. He came into what is known as the middle income group and he had to pay 10/- a day over a period of three months. It is quite obvious to everybody that a man earning a maximum of £9 odd a week and a minimum of £8, with six children and an invalid wife, is not able to pay 10/- a day for three months.
Admittedly there is an escape clause whereby the county manager can use his discretion. I have no particular reason to complain about my own county manager or about any other county manager to whom I have written on behalf of such people but I want to stress this to the Minister. In his opening statement, he drew attention to the fact that the cost of the health services is now running into £17,000,000 a year and as far as I can remember — I have not got the figures before me — the figure has increased by about £1,000,000 since last year.
Experience in the United Kingdom. the only place where we can find parallel conditions, shows that it is one continual struggle to keep the figures within bounds. The Minister in his statement makes it obvious to everybody that that is what is happening and that the figures are running so high that it is the Minister's intention —and I do not blame him—to try to restrict expenditure in every way so that this country may be able to meet its obligations. That would be all right if everybody were satisfied with the service. You cannot expect everybody to be satisfied with everything but I know of no other public service which is subjected to such criticism as the health service at the moment.
I have cited this case to the Minister because it is a case in which the health card was refused and people suffered considerable anxiety. What chance had the wife who was away in hospital of recovering when she felt the whole time that she was costing the family £3 10s. a week and thinking of the children at home who were dependent on the husband's salary to keep them in food and clothing and so on? Admittedly after representations had been made, the matter was adjusted and the health authority in my constituency were reasonable and mitigated the expenses. It is true to say that a manager has paramount powers under the Act and if he so wishes he may pay certain bills and mitigate the expenses of particular individuals without giving them health cards.
The reason I cite these cases is to draw the attention of the House to the fact that if you have hard and fast rules in relation to dealing with sick people, it is not satisfactory. I know another case of a family with a valuation of just over £50 — actually, £51. A daughter was suffering from poliomyelitis and had to spend a prolonged period in hospital. They were not entitled to any benefit whatsoever under the health services and had to pay about £7 a week. They had to pay all the medical bills, for massage and so on, and there was a sizeable family as well as this girl, who was the eldest daughter.
I applied to the local authority on their behalf and I received a reply saying that they were not entitled to any benefit as they were over 50 valuation. Again, the Minister may say that there is a loop-hole whereby the manager may use his discretion in certain cases. Again I refer to the ever-increasing costs of the health services and the struggle that county managers have to wage the whole time to endeavour to keep expenses within the rates. I know the difficulty every member of a local authority has to face with a continual rise in the rates. That is not due to the ordinary social services; it is due to the health services. I maintain that the health services are not giving the benefits they were intended to give. Someone may say it is easy to be wise after the event. I am not being wise after the event, as I said that constantly before when it was being decided by a majority that such should be the pattern of our health services.
I sympathise with any Minister for Health and any local authority trying to administer what I regard as a public futility. It is a terrible thing to see money which is designed for a specific purpose not producing the results it was intended to produce. I feel that if there were a new look at the administration of the health services, from beginning to end, the benefits could be spread out far more evenly.
There is another point to remember as well. Those who advocate that the State should do everything — and I do not agree with that line of thought —are exposing practically every family to a means test. It is a well-known fact that anybody who wants to benefit from the health services today is subjected to a means test. What happens is that a Deputy or councillor writes to the health authority and makes representations on behalf of certain people, that they are entitled to certain benefits, and the first result is a means test. It is referred to the home assistance officer, as I think he is called. He refers it to the local home assistance officer and there is a means test.
There is then a disclosure of personal medical matters because if it comes to a means test, it must be found out how long the person will to be in hospital and all those facts are considered by people who are not medical people. I am not saying that they will reveal the facts, but they are not bound to secrecy and they have got to divulge to the county manager and the health authority what is wrong with the person and how long he will be in hospital. For that reason, I suggest it is not possible to have a hard and fast rule as to who is entitled to a health card. I practised as a doctor in this country some years ago—not as a dispensary doctor— and my experience was that we had not got these difficulties before. One always knew who was entitled to free treatment and who was not. Perhaps, when the Minister is replying, he will be able to tell me who is entitled to a health card and who is not.
The answer is that under our wonderful legislation the insured classes are so entitled. A man earning £6 a week and who has one child may not be in the insured classes, although I think he is entitled to the privileges to which those who went before him were entitled. A man with six children, earning £10 a week, may not be in the insured classes. It is worked out according to plan, according to the valuation of land that is worked, according to the wage return and according to the number of people in the house. I have known health cards to be refused because of the income going into a certain house, and I have known them to be refused in the middle income groups because there were four or five wage earners in the house. In some cases, there may be two married groups in the house, but that does not matter. If they have the same name, they are regarded as the same family, their total earnings are taken into account and they are denied the benefits. We are trying to administer a system which is totally unsuited to the Irish people. I have said that in the debate on every Health Estimate. Some time, perhaps, someone will realise it is true.
Deputy O'Higgins suggested that the Minister should set up a commission to examine the health services. That seems to me to be a sound suggestion. The Minister has told us that costs are rising. He has indicated, quite fairly, that he thinks costs are really going beyond what the State can carry. I am giving the point of view of an ordinary Deputy — and I feel certain that it is the opinion of everyone else— when I say that the services are unsatisfactory. It seems to me that a solution might possibly be found by setting up a commission to consider these services, as Deputy O'Higgins suggested.
Another point in the Minister's opening speech which interested me was when he said there was a certain difficulty — at least this is what I took him to mean — in the dual control, that portion of the costs is carried by the local authorities and portion by the Central Fund. The original idea was that half would come from the Central Fund and the other half from the local authority. I suppose it was wishful thinking in those days that the taxpayer would not notice how much he was paying. It was supposed to cost only 2/-, or something like that, per head of the population. Now the taxpayer knows at local level and at central level what the cost is. I would be the last person to criticise those costs if people were getting benefits.
Does the Minister think that the dual control, as I call it, of administration by the local authorities and the central authority makes for efficiency? Surely it must lead to extra officials and extra correspondence. I have been long enough in public life to know that extra costs mean an extra file, and once you get an extra file, extra officials are needed. When you get a new file going, everyone must have their little say on it. It must go from one level to another and everyone must express his opinion. That is what is known as administration, but that is costly. It costs money and it does not produce any benefit for the people with whom the House is concerned today, the sick people.
The Minister should consider Deputy O'Higgins's suggestion. If he decides to appoint a commission to review the administration of the health services, its terms of reference should include the advisability of transferring the administration to a central control and have it centrally directed under one administration, rather than having the dual system which does not seem to make for efficiency.
I do not know what actual authority the Minister has at the moment with regard to the health services. Perhaps when I get time to read Mr. Hensey's book, I may know more about the functions of the Minister for Health generally. I feel that if I were to write to the Minister with regard to the matters I mentioned — the one relative to the health card and the other to the valuation of over £50 — his reply would be that it was a matter for the local health authority. I do not know whether or not it is true, but I feel that there is some idea in the Department— I am not quite sure what it is — that there is a very trenchant case for having the matter dealt with at either one level or the other, rather than both.
In his opening statement, the Minister mentioned the reduction in the figures relating to T.B. We must all feel glad of that. There has been a dramatic change with regard to T.B. over the years in this country, and I think it is fair to remind the House that the dramatic decline in the incidence of T.B.—not only medical pulmonary T.B., but the bone disease known as surgical T.B.—started from the time of the first inter-Party Government in 1947. A great many of our T.B. institutions are closing down at the moment for want of patients. They can be used for other purposes, and I shall perhaps have a few comments to pass on that later on.
The Minister mentioned that the two primary diseases that seemed to be on the increase are cancer and heart disease. He specifically mentioned the fact that lung cancer was increasing, and it seems to be the opinion of the Minister, and his officials, that cigarette smoking, or tobacco smoking as a whole, is largely responsible for that regrettable state of affairs. I wonder is that the cause or is it not. We must regard the matter from two angles. First of all, I feel that in recent years there has been a much more accurate diagnosis of lung conditions, and it is possible that many of these cases which were in fact lung cancer heretofore, were not diagnosed as such. It is possible that they passed into oblivion diagnosed as other conditions. I do not know if there are any statistics to show that the consumption of tobacco has increased to any extent. To my knowledge, there were very many people who smoked very heavily over the years and did not necessarily fall victims to lung cancer, but I have known people who never smoked at all to die of lung cancer. It is problematical whether smoking is or is not the cause.
I should like to suggest to the Minister what I consider to be a very likely cause, and perhaps his Department might carry out some research, or have some observation made on the point, anyway. In recent years, there has been an increase in the use of diesel oil and, as everyone knows, diesel oil gives off the most pungent and unpleasant fumes. Anyone driving a car behind some of these heavier vehicles which blow off diesel oil, will automatically close the car windows against it. Apart from that, in hot weather in any city, there is a continuous smell of diesel fumes.
I believe there is a high incidence of lung disease in stokers who work in the oil rooms on ships. British Navy statistics show that it is not unusual for stokers to develop this very dread disease, so it seems to me that it is most likely that it is a modern cause of cancer of the lungs. I do not know really how it could be dealt with, but it may be that with science advancing as it does to protect humanity against the dangers which threaten it, some scheme for dealing with the problem may be devised.
Perhaps when the Minister is replying he might be able to tell the House if he thinks there is any foundation for what I said. If he does, he might tell us if he proposes to take any steps to remedy the position.
The other condition the Minister mentioned is the heart condition. It must give this country very serious cause for thought. It is not peculiar to Ireland alone. Statistics over the past few years have shown a greatly increased mortality from heart conditions in quite young people. It is probably true that they find themselves continually in a state of mental anxiety. Heart conditions are far more prevalent among the middle classes than any other class. They affect the income of salaried classes, the white collar workers, those who are struggling to make ends meet, those who find themselves — and this brings us back again to the health services — bereft of the benefits in relation to free treatment. They affect people who are constantly worried, people who are anxious lest, if anything goes wrong with them they, the breadwinners, will be removed from their family and the source of revenue they give the family. For that reason this is a matter which must engage the attention of the Minister and his Department.
Is there any remedy for the condition? Take the case of a person who is outside the immediate scope of the health services or even in the middle income group and who is unfortunate enough to develop cardiac thrombosis, which needs prolonged rest, prolonged treatment and, above all, total freedom from anxiety. Here is the particular type of case that is liable to be afflicted with heart condition. That is the particular type of person, who through the variety of circumstances we have mentioned, will be forced to return to work again sooner than is desirable from a health point of view.
I heard recently of a member of my profession who got one of these attacks. He had six children. He could not spend long away from his work; he had to return to duty again. Not very long afterwards he died suddenly. That is only one case. There are literally hundreds of these tragedies happening around us. It is a matter that should be considered in health administration.
I do not know how the Minister can deal with it but I know that there are certain benefits relative to certain diseases such as infectious diseases, whereby the individual affected is relieved of a great deal of the responsibility. In the administration of the present Acts it might be possible for the Minister to devise some scheme whereby heart cases would receive particular consideration. It is necessary in view of the statistics the Minister quoted and in view of the tremendous national loss of men in the prime of life who are being removed from their families. The treatment with regard to heart cases is costly and prolonged. The drugs are expensive. Above all, freedom from anxiety is of paramount importance.
I am glad the Minister is to appoint a commission to deal with, I think, mentally defective persons. I want to tell him what I know about this facet of the medical services. No matter what anybody says, in every county in Ireland there is a waiting list. It forces parents to keep children for whom they are unable to do anything and who are a hardship to them. It is no advantage to the child to be kept in the home simply because the parents cannot get it away. The Brothers of Saint John of God and other religious have done sterling service in rehabilitating, looking after and taking these children. Their difficulty is clear. There is a limited amount of accommodation and there is also a considerable limit to the vocations they are able to get. In other words, the personnel of the Brothers is not as numerous as they would wish it to be. They are unable to find people ready to dedicate their lives to this very exacting task— and it is an exacting task. They are limited in their accommodation, in their funds and in their staff. Where they have not sufficient of their own staff they have to procure staff outside and for them that is a much more costly business.
The Brothers of Saint John of God give all their time and energy to this work. Owing to lack of accommodation there has been a hold-up in the admission of cases. There are many cases they are not able to take in. When they do take them in, some are there for all time. They may have them for many years. They have to keep them there. They have no hope or opportunity of passing them on.
There are other cases which can be trained to do a certain amount and these cases are not so bad. To a certain extent, they can fend for themselves. These are cases they could possibly lay off. I want to make a suggestion to the Minister. I believe a lot of children in these institutions have been treated and have improved to a certain extent. They will probably never completely recover but they could be passed into an institution where they could work under supervision. I have in mind an institution where only a limited staff would be required, where one person under trained personnel could possibly do the work of 20 in an ordinary institution. I have in mind putting them into institutions where they could run the farms, produce the food they are eating, and so on.
Such cases could be trained in these institutions to lead some sort of useful life afterwards apart from the fact that they would ease overcrowding where they are at present and allow more patients to be taken on. It would help them to feel they are leading a useful life. It might be possible for the Minister to take over a country house in certain areas with a good deal of land attached and hand it over to these institutions. They then would have the staff to man them. They would not need a very big staff. They could transfer some cases who are cluttering up the places where they are at present and in whose place other cases could be admitted.
There is no need to stress how urgent this is. The Minister knows as well as I do that unless you take these cases at a very young age and commence to train them it is very hard to do anything with them later on. I should like the Minister to give that matter his consideration.
I am not very clear as to the position of public health administration in this country in regard to emergency maternity squads. It is the practice in other countries to have emergency squads with blood transfusion facilities and every modern appliance necessary who go out in an emergency to deal with cases in the homes. The voluntary hospitals, many of which find themselves financially embarrassed at present for reasons into which I need not go, have emergency squads which they send out but it seems to me that, if we are trying to introduce a national maternity system throughout the country based on certain centres, we should have in all those major centres, an emergency maternity squad which could be sent out at short notice. It is a known fact that many lives are lost because of the acute haemorrhages that may be associated with these cases, which have to be dealt with in the house without being moved. I do not know the position here, whether the special services provide for any service such as that. If they do not, and if they do not feel able to provide it, I do not see why the Minister should not call on the special voluntary services as they exist. In the case of the special services, where they are required, they should be adequately remunerated. They have taken the risk to build up the service in the interests of the public and it would probably be better to provide this service in a voluntary way. I always think one gets better service when a matter is dealt with voluntarily rather than by a State administered scheme.
The Minister has some function is the appointment of surgeons. It is a limited function; I believe it consists of laying down the conditions of appointment. If a well-qualified surgeon seeks an appointment as county surgeon, and is competing with somebody who has a much lesser service in an outside hospital, although he may have several years in an Irish local authority hospital he appears to be ineligible for appointment as against his outside counterpart. As far as I can understand, the reason is that when appointing surgeons to hospitals we do not recognise any hospital surgeon unless he has been resident or acting surgeon to a teaching hospital. To me that seems very foolish.
I know several cases where surgeons who had been doing the job temporarily and very efficiently over a considerable period were not appointed to the permanent post. One such case happened in my own county, there was another in the Midlands and another, I think, in Cork. The surgeons concerned had been doing temporary duty for three years and were fully qualified surgeons with the degree of F.R.C.S. of Ireland, England and Scotland or whatever surgeons' degrees there are, but due to the fact that they had spent most of their time in an Irish hospital which was not a teaching centre they were ineligible for appointment.
I think a simple order by the Minister would settle that question. It would only be necessary to state that in the selection of a surgeon, seniority of service in an Irish hospital even though it is not a teaching hospital should be recognised, and would count as experience for the appointment. If I am wrong in this the Minister may correct me but I can give him privately several cases in point. There was one case where the temporary service was over a period of eight years and yet the candidate was not eligible for appointment nor was he eligible for appointment in several other hospitals for which he applied.
