Committee on Finance. - Vote 58—Health (Resumed). – Dáil Éireann (16th Dáil) – Tuesday, 12 Jul 1960

Committee on Finance. - Vote 58—Health (Resumed).

Debate resumed on the following motion:—

That a sum not exceeding £6,525,600 be granted to complete the sum necessary to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1961, 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. Manley

The most disturbing feature of this Estimate is the magnitude of the increase which we have to face every year. The increase is now very high. The provision for the coming year is £17,800,000. It is all the more significant and all the more surprising when we realise that we are a very small community of some 2,850,000 people, and that only a small percentage of our people benefit from the health services. Perhaps, the Minster in his reply will give us the exact figures. From a reply to a question here during the year, I think the figure is 28,000 in the lower income group. I must say that I am ignorant of these facts and I should like to have them from the Minister.

With the Minister I sympathise in his expressed desire for economies in health administration. I fail to see where they are to come from because health administration, from its very pattern, will inevitably be costly. If we could segregate the figures for administration from the figures actually paid out in benefits, we would be in a better position to understand where economies could be effected.

We have to realise that health legislation is operated through a whole system of officials down the country. Every county council has its health authority and in that health authority there are officials who have to make records, inquiries, investigations. They have interviews of various kinds so that it is a long and involved process. It is very tedious and complex for the officials who have to face up to these responsibilities. We have a health authority in Cork and what is amazing about the officials in that health authority is the complete intimacy with which they handle the various problems and the extraordinary objectivity and impartiality they show. They are also efficient and competent. It is a tribute to the officials both in the health authority and the sanatoria. The sanatoria section have been amalgamated since the 1st July. I cannot see, therefore, where we are to secure economies in view of that pattern in the service.

The Minister mentioned a booklet which he intends to provide. I am sure he is aware that some local authorities have already provided a very simple little booklet giving in their respective local areas the names of the hospitals and the types of service available. I humbly suggest that if the Minister is going to issue a booklet now, the cost will run into thousands of pounds. He says he will see that there is one in every home. I can assure him that 70 per cent. of these will not be read. Many of them will not be understood by the people who claim benefits. Eventually, the people looking for information about the health services will have to go to the officials concerned or to the public representatives for the area. Therefore, I think it is a waste of time and money.

I should say that if such a booklet were issued by the respective local authorities, it would have a local appeal. It would be local in its character, containing the names of the hospitals and so on and the location of the services would all be set out in that booklet. For that reason, it would have a far greater attraction than the booklet which the Minister contemplates issuing in the near future.

I have no doubt that the idea behind the issue of the booklet is the very best. The Minister wants to be helpful and to give the information to the people seeking it. I do not think they will look for it in a text book of any kind. No matter how simple the book is, it is for those people an abstract text book and they will not be inclined to follow it. We ourselves get reams of reading matter connected with the various Departments. Personally, I do not read a fraction of them. I have not got the time. Many of the people will be preoccupied with business. Their wives will be preoccupied with domestic matters. They will simply not have the time. With the radio, the advent of television and all the reading material, such as magazines, available, they are not going to fall back on such a heavy subject as health legislation.

The Minister gave encouraging figures about the incidence of tuberculosis. We are all very glad that the measures taken in recent years obviated the danger of a scourge from that disease again. The figures given in regard to heart disease and cancer are rather disquieting and offset to a considerable degree the very encouraging position in relation to tuberculosis in this country today. Of course we shall have to wait for greater research to get the real line on those, but I hope eventually, like tuberculosis, the scourges may be conquerable, to a certain degree at all events.

The Minister dwelt at length on his hospital building programme and his policy is to be cautious and to build up a certain reserve fund, except for expenditure for essential needs. I agree with the Minister on that. I think his policy is sound and correct. We do not want to see hospitals dotted all over the country. We have redundant sanatoria now and they will be gradually converted to uses for people suffering from other diseases. In the course of time many of those may become redundant with the advances of medical science and with the advanced treatment we now have in regard to various diseases. It is true that there is overcrowding at the moment in some hospitals but doctors have told me, in Cork at any rate, that if only they could get rid of the chronic patients there would be no overcrowding problem. Some of those patients remain on for months and even for years. Some of them have no homes to go back to or, if they have homes, there is nobody there competent to take care of them, or the people in the home do not want to have them back.

That is a problem that focuses attention on the necessity for finding homes for aged persons. I am glad that the Minister has that in mind. It is one way of relieving pressure in the hospitals and providing some comfort for these people in their old age, away from the hospital atmosphere. These homes could be run by a community or by committees and they would be places in which these people would be very happy.

The Minister also referred to mental hospitals. There is urgent need for extensions to some of these hospitals. He also mentioned the voluntary hospitals. Considering that the voluntary hospitals have given such valued service to the people for centuries they should be an important consideration with the Minister and his Department. I know that some voluntary hospitals have plans for contemplated extensions and are awaiting grants or sanction to go ahead with these extensions. Would it not be more sensible, and a better method of meeting their demands, to get them to reassess their plans so that they could be carried out over a period of years and would not impact too heavily on the Hospital Trust Funds. These demands could be implemented gradually over a period of years, and, at the same time, save the reserve which the Minister has in mind.

I was rather disappointed that the Minister did not put greater emphasis on the voluntary health insurance scheme. I know many people in the middle income group who are participants in the voluntary health insurance scheme and they believe that the independence and the security it gives them for the future is an attraction. They are quite happy and content to remain on in the scheme even though they may be eligible for benefits under health schemes for the middle income category. It was a pity that this scheme did not take precedence over the Health Act. We would be in a much happier position to-day if that had been done. However, I suppose we learn by degrees.

In the Civil Service they had a health service of their own. They made a contribution to the health services and it was a magnificent one but unfortunately it had been known for years that the health services were to be made available and those who wanted dentures or medical treatment waited until this scheme was in operation and, I have been informed, the demands impacted so heavily on the fund that chaos resulted. The teachers' organisation have a magnificent health scheme and, for a very paltry sum, the benefits are most generous. I think the only way we can economise in health legislation is to encourage those groups and organisations to look to the individual, independent insurance scheme of their own. In that way, they will be making provision for themselves and they will be helping to restore that independence and dignity of the human person which these health regulations have tended to destroy so much over the years.

Minister for Health (Mr. MacEntee)

This debate has been helpful in some respects. Before I deal with some of the heavier matters touched upon by some Deputies, I should like to dispose of some of the less complex questions which have been raised. Before doing so I should like to say how much I appreciate and welcome some of the contributions. Nothing can be more helpful to a Minister who is faced, as I am, with the difficult problem of making a system work, which very many of those who have to work it dislike heartily, than healthy and constructive criticism. Even if the critics merely spotlight weaknesses in the system and administration of which I, myself, am keenly aware, it is no waste of effort on their part to point them out again to me. At least they afford me the opportunity of explaining the position, as I see it, in regard to the particular matters they raise. The special approach of their several minds to difficult issues scarcely ever fails to bear fruit and in this context and from this context I do not exclude the sounder portions of the speeches made by my predecessor and even those made by the Leader of the Opposition. The friends of Deputy O'Higgins had to be gratified by a flagellation act and as for the Leader of the Opposition, he has still to establish himself as an effective leader and hence the display of stage thunder to which an empty House echoed almost a fortnight ago.

In my opening remarks on the Estimate, I pointed out that diseases of the heart and various conditions of malignancy had created very serious problems for our health services. Speaking on that matter, Deputy Esmonde, with the support of Deputy Booth, argued that as freedom from worry was of great therapeutic value in the treatment of heart conditions, those afflicted with coronary and cancer conditions should receive monetary help as they would if they were suffering from an infectious disease. What the Deputies lost sight of in this connection was the simple fact that the community was prepared to tax itself heavily in order to encourage tubercular individuals to undergo isolation and treatment, and that the public at large had a very substantial interest in the success of any scheme to eradicate tuberculosis for the reason that it lessened the risk to everyone of becoming infected. I venture to say that the public in general would not be moved in the same way and certainly not to the same degree in regard to cancer or heart diseases. A member of a household in which there is a case of heart disease runs no risk of being infected himself, and through himself infecting others. Quite the contrary is the case with tuberculosis and everyone now knows that.

The present cost of the infectious diseases maintenance allowance scheme is £327,000, and to expand it to cover heart and cancer cases would probably cost another £1,000,000 or more. If I had a further £1,000,000 at this moment to expend on health services, I should in conscience spend it in a way which would confer the most widespread and general benefits. I would be bound to spend it, say, on the improvement of our dental services, and particularly our school dental services, or on some other similar service where the benefits accruing would be very widespread.

Moreover, it has to be remembered that a number of cancer and heart cases benefit under existing social welfare schemes. Insured workers can draw disability benefits which under the new Social Welfare Bill will be payable at the following rates: a single person will receive £1 12. 6. per week; a man with an adult dependant £2 12. 6.; a man with an adult dependant and two children, £3 12. 6.; and a man with an adult dependant and five children, £4 12. 6. For those reasons and others which I need not detail, it would, in existing conditions, be impractical and unjustifiable to single out sufferers from heart and cancer conditions for exceptional treatment as compared with persons suffering from other types of illness.

Deputy Booth was also anxious to get some information on the implications of the European Agreement for the Exchange of Therapeutic Substances of Human Origin which was signed by Ireland in September, 1958. The purpose of that Agreement is to provide an international blood bank which can be drawn upon to meet urgent needs. The parties to the agreement undertake to make the therapeutic substances in question available to each other on the express condition that no profit is derived from them, and that they are used solely for medical purposes. To facilitate this arrangement, the Agreement provides for the rationalisation of different methods of preparing, preserving, packing and dispatching blood and its derivatives. So far, no request for assistance in accordance with the Agreement has been made to this country.

Deputy Esmonde said that he was not very clear as to the position in regard to emergency maternity services. The position is that for years past the three voluntary hospitals in Dublin, Erinville in Cork, Airmount in Waterford, Our Lady of Lourdes Hospital in Drogheda, and Portiuncula Hospital in Ballinasloe have all provided on behalf of the health authority convenient to them, obstetrical emergency services. As well, similar arrangements existed, though I think on a less formal basis, in almost all the remaining areas in the country.

However, in order to ensure that the best possible emergency services will be available everywhere, the local authorities have been asked to give particulars of their existing arrangements. The information sought includes precise details of the scope and personnel of the services and the hospitals on which they are based, the nature of the resuscitation services available, the extent to which additional medical assistance could be provided in a patient's home and the facilities for conveying mothers and infants to hospital, when necessary. Almost all the authorities have furnished the required data and it is now being closely studied.

I come now to one of the less agreeable contributions to the debate. From Deputy Crotty's appearance, one might take him to be an intelligent well-informed man. What is one to think about him when one reads what he said on 30th June regarding the regional orthopaedic hospital in Kilkenny. I quote now from column 765, volume 138, of the Official Report where he alleged:

...we have a regional orthopaedic hospital with no orthopaedic surgeon resident. The surgeon lives in Waterford and if somebody breaks an ankle or a leg in Kilkenny, we have a regional hospital with every appliance, operating theatre and everything, but nobody to operate.

That would be a woeful state of affairs truly, if it were true, but it simply is not true—not a single word. I do not think Deputy Crotty has been away from Ireland for the first half of this year so his ignorance of the position in Kilkenny Hospital is not due to his prolonged absence abroad. I do not think, either, that in Kilkenny he leads the life of a recluse. How then are we to explain the ignorance which he displayed here of the fact that a highly qualified orthopaedic surgeon has been attached to the hospital since December last and is actually living in the hospital residence? How has it happened that Deputy Crotty is unaware of the fact that the former resident registrar of the hospital is still serving as an extern registrar and resides in Kilkenny town, about three-quarters of a mile from the hospital? If Deputy Crotty suffers from blind spots in his knowledge, he ought to take stock of what is going on around him, particularly when he labours under a schizoid condition and tells us of a magnificent orthopaedic hospital which he said is fitted with every appliance, but which, 30 odd words later, he describes as "merely an auxiliary hospital and is not even fit for that although it was built as a regional hospital."

Whatever the explanation for these curious misstatements, I shall readily forgive Deputy Crotty if he adduces one little fact. Will he give the name of any single person requiring the services of an orthopaedic surgeon since January 1st of this year who had to be transferred from Kilkenny town to Waterford city because of the fact that the services of a fully qualified experienced orthopaedic surgeon were not available in Kilkenny? If there is any foundation at all for the strictures which he passed upon me, he ought to be able to furnish that information without delay.

The same Deputy also criticised the county manager in Kilkenny because a review of the medical register had taken place within the past few months. He was particularly anxious to know where the manager got his inspiration. He got it, I can assure the House in the most prosaic way possible. He read an Act of this Oireachtas—the Health Act of 1953, which provides by way of regulations made under it that the medical register has to be renewed annually. Therefore, there was no question of the county manager receiving any inspiration from the Minister for Health. He was merely discharging the duty which this House has imposed upon him.

Deputy Healy's speech demonstrated how closely he has studied the Health Act, and I would advise Deputies like Deputy Crotty to read it. Many, I think, would learn from it that the medical card system is much more elastic than is commonly believed. As the Deputy pointed out, where the circumstances justify it, the person may obtain, in a specific instance for a specific purpose, all the benefits to which the possession of a medical card would entitle him.

Deputy Healy also made a particular plea for an arthritic who was incapable of working. The position is that under the Health Act the maximum amount that may be granted by way of disability allowance is 20/- per week. The sum may appear rather modest, but these allowances in the aggregate are costing the taxpayer over £700,000 a year. There is, however, nothing to prevent the Cork public assistance authority from granting the sufferer to whom Deputy Healy referred home assistance to any extent it wishes.

Deputy Healy also stressed the need to provide a residential clinic in Cork for sufferers from cerebral palsy. I accept the fact that the need exists. Unfortunately, it is but one of our needs. Though money is not available for a new building, the needs of sufferers from this condition are constantly in my mind whenever I am considering the use to which a building which has become redundant can be put. Deputy Healy also reminded me of the fact that additional accommodation is required for the Cork dental school. Whenever the opportunity offers, I shall give sympathetic consideration to the admitted needs of that institution.

Deputy Manley asked how many are covered by the health services. The Deputy must have heard me incorrectly when I made reference to this or else he has got his figures wrong. The Deputy said that 28,000 people in the lower income group were covered——

Mr. Manley

Twenty-eight per cent.

Mr. MacEntee

Yes, it was a slip of the tongue on the Deputy's part. Therefore, he is aware of the fact that 28 per cent. of the population is so covered. The total proportion of the population covered by Section 15 for hospital and specialist services is estimated at about 85 per cent.

The Deputy took exception to my intention to issue a booklet on the scope of the health services. He says the county councils have issued comprehensive leaflets. That is quite true, but the leaflets covered only the hospital and specialist services and the maternity and child health services. They are based, of course, on drafts issued by the Department, but they cover only two services and do not provide the answers to many questions which are often put to me. I wish to give the people a full opportunity of putting these questions to themselves and, through the booklet, receiving the correct answers to them. It may be, as the Deputy suggested, that a number of people will not read the booklet and that many who do will not understand it; but I am sure the majority of our people are intelligent enough to read and understand it and, when they are sufficiently interested, to have resort to it.

Deputy Dr. Browne urged me to give greater publicity to the facilities available in relation to poliomyelitis vaccination. The local authorities were requested by the Department some time ago to give public notice of the schemes by advertising in the Press; and more recently, having regard to the incidence of the disease, have been requested to do so again. In addition, the Department proposes to undertake in the near future an advertising campaign pointing out the benefits to be obtained from poliomyelitis vaccination. But of course I do not think it is necessary for us to carry full page advertisements in the national Press in order to bring home to parents their duties and responsibilities in relation to their children in this very serious matter. We should be able to convince them by a more modest expenditure of money and paper that it is highly desirable, and indeed imperative, that all parents should avail of the scheme.

Deputy Dr. Browne also had a great deal to say about the Voluntary Health Insurance Scheme. He stated that the existence of the scheme was not a substitute for a proper, comprehensive medical service available without charge to every member of the public and that the schemes provided by the Voluntary Health Insurance Board had not made adequate provision for people not covered by the public schemes. In this connection he stressed the fact that only 80,000 of the total population were covered and that the schemes covered only short term hospital and specialist treatment and did not provide for the person suffering from a chronic illness. As I pointed out in reply to queries put to me by Deputy Manley, the Health Act provides for essential services, free or at low cost, for about 85 per cent. of the population. It was never intended that the Voluntary Health Insurance Scheme should provide full comprehensive cover for the remaining 15 per cent. It is expressly provided in the statute that the scheme must pay for itself, taking one year with another, and if chronic cases were to be admitted, the premiums, naturally, would be very much higher than they are and consequently the schemes would not be anything like so attractive. The Health Act of 1953 further provided that the Health Act schemes would be available to persons outside the income limit specified in the Act if serious hardship would result from the inability of the patient or his relations to pay for treatment.

I am glad to say that the number of persons insured under the Voluntary Health Insurance Scheme has been growing steadily and there seems to be no doubt that within the next few years these schemes will provide a very substantial measure of protection against the heavy cost of illness to the greater part of the 15 per cent. of the public not covered in the Health Act schemes.

Deputy O'Higgins seemed to think that in my opening statement I did not devote enough time to praising the schemes and encouraging people to take advantage of them. Of course, as the Deputy knows, under the Minister for Health, and the Department as well, there are a great many ancillary bodies operating—the National Organisation for Rehabilitation, the National Mass Radiography Association, the Blood Transfusion Association, the National Cancer Association and a dozen others. I did not mention every such body which has any association with the Department but I did make special mention, apart from all others, of the Voluntary Insurance Board. I mentioned the fact that it was developing in a very satisfactory way.

Deputy Dr. Browne was trying to make a point, the precise object of which I was not quite able to follow, of the fact that the mortality among infants of parents of the professional classes was substantially lower than it is among children under one year of manual wage earners. I think what he is trying to ask us to accept is that the heavier mortality among children, under one year, of manual workers is due entirely to the alleged fact that proper medical services were not readily available to them. Of course there is a great deal more in question than just mere medical attention. Housing conditions in 1946 were not nearly as good as they are now 14 years later because housing had been substantially slowed down during the war years from 1939 on, and in fact it did not get going at full speed again until about 1951. There is also the question of sanitation and perhaps an even larger factor is the different marital habits of the professional classes from these of wage-earners and manual workers.

One knows that the general demographic trend all over the world is for people in the professional classes to have fewer children and therefore longer intervals between each birth. The position is quite the reverse in the case of others who are in the lower economic stratum. Accordingly, it is not to be wondered at that where you have many births per family, the mortality rate will be higher. I think Deputy Dr. Browne indulged in special and specious pleading which only tends to confirm persons in their view that he is a man who is quite incapable of making a rational approach to questions, such as these, where there are many factors involved.

It is not surprising that Deputy O'Higgins seemed to be in marked disagreement with almost everything that had been done by his successor. It is natural enough that this should be so. If his attitude in regard to health matters were the same as mine, the Deputy would be where I am, not where he is. It is a pity the Deputy is not able to adjust himself to that fact; it is a pity because humility is the beginning of wisdom and if the Deputy did examine the position objectively, he would realise how much better everything now is than when he was in charge. In any event, he should recognise that it no longer pays anybody to play politics with health services or with the Minitry for Health.

The Deputy made great play with the suggestion——

Mr. Dillon

The Minister has lost it.

Mr. MacEntee

No, I just want to get the figures; that is all I am looking for. Deputy O'Higgins made great play with the suggestion that we were spending only £1 per head on persons who were covered by the general medical services card and he quoted figures for the year 1957-8 tending to prove that. He said that we spent £879,000 on these general medical services to cover 850,000 persons. It is possible to frame statistics which will be quite misleading and indeed quite foolish. It is not true that we are spending only £1 per head upon sick persons who are covered by the general medical services card. There are many who hold these cards and who, thank God, enjoy good health and every member of their families enjoys good health. If they are not ill, they do not need to go to the doctor or to buy medicine

The statistic which the Deputy adduced has no practical significance. If we really want to know what we are spending per patient—which is the really critical statistic—we should find out—perhaps the Deputy might be able to do it; I have not been able to— how many of the holders of medical cards received treatment, for how long, and what was the nature of the illness for which they were treated. We might then by correct weighing of all these values be able to get some sort of statistic that would be worth while in trying to establish the case which Deputy O'Higgins tried to establish. But, let me say this—first of all, that the figure which he gave was the figure for 1957/58. No responsibility or blame or criticism attaches to the Deputy for giving the figure relating to that year. It would be the only one, perhaps, which was available to him.

The provision in the Estimates for the current year, 1960/61, under the heading described as General Medical Services, is £1,060,000 and is made up of salaries of doctors, £698,000; medical supplies, £287,000; other expenses, caretakers, upkeep of premises, etc., £75,000. The Deputy, arguing from the 1957/58 figures, arrived at the conclusion that the average cost per person covered was 16/- in salaries and 4/- in medicines. In arriving at these figures, he would appear to have assumed that all the costs other than medicines were for salaries but the correct figures, accepting the total of 850,000 persons covered by the cards are as follows: salaries of doctors, 16/5d.; medicines, 6/9d. and other costs, caretakers and upkeep of premises, 1/10d.

I may say that the Deputy also appeared to be under the impression that the salaries of staffs engaged on general administration—office staffs, and so on —and on the assessment of applications for general medical service cards, like assistance officers, were included in the General Medical Service item appearing in the Estimate. That is not so because these administrative costs are included in the item "Other Services" and assistance officers' salaries do not rank for the health service grant, so they do not come into the Estimate at all.

The Deputy also misstated the cost of medicines and drugs under the British National Health Service. He stated that was 26/- per head of the population and he proceeded to compare that with the figure for medicine of 4/- per head of the population in this country. In fact, as I have already pointed out, the figure of the cost of medicine here is almost 75 per cent. higher than the 4/-. It is 6/9d.

It is true that the total cost of supplying medicines and drugs under the British National Health Service in 1958 amounted to £65½ million but it is not correct to assume that this was entirely in respect of drugs. The estimated breakdown of these gross payments is this: dispensing fees and payment for services outside hours, £13,080,000; overheads and profit, £9,535,000, and cost of ingredients and allowance for containers, that is to say, the cost of medicines, £39,490,000 and you see that works out at 15/3d. per head of the population.

There are two factors which tend to increase the costs in Britain as compared with this country. The first is that under our combined purchasing system we can, in fact, purchase drugs and medicines at lower prices than is the case in Britain where the purchases are made from wholesale chemists. The second factor is that there is a very long waiting period for admission to many of the hospitals in Britain. Patients who in this country would be treated in hospitals or similar institutions are treated for long periods at home in Great Britain and during this waiting period they are supplied with medicines and drugs. In this country, as I have already said, the waiting list is very short and the same expenditure under this heading of General Medical Services is not necessary and is not, of course, incurred.

I was saying that it is a pity that Deputy O'Higgins, my predecessor, had not taken a more objective view of the position of the health services as they are at the moment, because, as I have also said, humility is the beginning of wisdom. If I cannot give Deputy O'Higgins any laurels for his humility, I cannot forbear some admiration for him for his audacity. I wonder what Deputy listening to him on June 30th could conceive it possible that when Deputy O'Higgins left office in 1957 he left behind him not only financial chaos but bankruptcy and desolation in the architectural profession and in the building trade. Not only had every penny which had accrued to the Hospitals' Trust Fund during the years preceding 1957 been spent but in January 1957 an advance of £100,000 had been secured against the proceeds of the Sweepstake on the Grand National in 1957, a race which, bear in mind, was not to be run until the following March. The position was so desperate at the close of the financial year 1956/57 that it was not possible for me to wait for final accounts of that Sweepstake and I, therefore, had to obtain a further advance of £600,000 on 1st April, 1957, to meet the commitments of my predecessor, Deputy O'Higgins.

Not only, however, did Deputy O'Higgins anticipate the Sweepstake income for 1957 by securing, as I have pointed out, an advance of the proceeds of the Grand National for that year but he proposed to continue to do so for some years. I suppose he would, in due course, have left his successor heavily burdened with financial obligations, to meet which that successor would have neither the reserves nor accruing income. As it was, when I took office in February, 1957, every voluntary hospital in the City, every builder engaged on hospital contracts and virtually every professional man who was associated with hospital work were dunning me for money. I think I am quite entitled to say that, thanks to my good management, we are able to meet our commitments and our obligations as they fall due and building is proceeding in a normal way instead of proceeding by fits and starts and convulsively like some person suffering from a nervous disease.

The Deputy in his speech also betrayed a Micawber-like mentality towards this question of finance. He said he was prepared to enter into commitments and he hoped that something would turn up which would enable him to meet them. There is a standing testimony to the wisdom of that policy. It is to be seen near Booterstown. Let any Deputy on the way out to Dún Laoghaire cast a look at Elm Park and see there the arcades of rusting steel which represent works that were begun by Deputy O'Higgins but which he had not the resources to continue. The Deputy charged me with twiddling my thumbs.

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

Mr. MacEntee

Deputy O'Higgins charged me with twiddling my thumbs. What did he expect me to do in the earlier years of my responsibility when my principal preoccupation was to find money to meet the commitments which he left behind? The Deputy spoke of the hospital programme which he drew up when the shades of the 1957 election were closing around him. It was not, I may say, a bad programme on the whole. It had a few political cutbacks but it was comprehensive and I agreed with most of it. All that it lacked, and it sorely lacked that, was the money to carry it out. However, it may interest the Deputy and the House to know that of the 40 projects on the programme decided by him, 12 schemes have already been completed and five schemes are actually in progress. The remainder are either being planned or have been deferred for the present as not being of great urgency.

Apart from the schemes included in the Deputy's list I have since approved of the undertaking of 59 other necessary works involving a total estimated outlay of about £1,000,000. Nine of these schemes have already been completed; five are in progress and the remainder are being planned. In addition I have given instructions that the planning of the major schemes of reconstruction and improvement works at county homes is to be pushed ahead vigorously. The estimated total expenditure involved in the county home scheme is £5,000,000.

All these achievements scarcely indicate complete inactivity in the hospital building field over the past two years. The great problem is in regard to the three major projects included in the building programme as originally approved, that is to say, the Cork Regional Hospital, the new St. Vincent's Hospital and the new St. Laurence's Hospital. On the basis of the estimates which have been put before me, these three schemes alone involve a total outlay of about £6,000,000 and it is quite clear, having regard to the position of the fund, that all three schemes cannot be allowed to proceed at the same time. This is especially so since the building of a new Coombe Hospital at a cost of £750,000 has been approved and commitments for other urgent works will involve considerable outlay.

Deputy O'Higgins also stated that had this programme been carried through, the new Coombe Hospital would now be in existence. While the-Deputy may have indicated that the new hospital would have been proceeded with some time, the official records in the Department indicate that in February, 1957, he had not decided definitely which two of the four major projects remaining to be undertaken should go ahead and an official minute dated 14th February, 1957, initialled by the former secretary of the Department states: "The Minister proposes to defer for the present any decision in regard to the two major projects in respect of which grant provision was tentatively provided."

Mr. T.F. O'Higgins

Will the Minister accept from me that that is not so? I had decided to postpone the Richmond and the Cork Regional Hospital.

Mr. MacEntee

The Deputy has challenged the policy which I have pursued. I can proceed only on the basis of the documentary evidence before me and I am not going to assume that the then secretary of the Department would have written this note on the file if he had not consulted the then Minister and had not secured his approval for it.

Mr. Dillon

I wish to raise a point of order which I hope will get the Minister's assent. While it is appropriate to proceedings to bring before this House any recorded Government decisions or other documents on record, it should not be in order to bring before this House confidential minutes which ordinarily pass between the Minister for the time being and the secretary of the Department. If that practice continued, it would become impossible to carry out the work in Departments because no ministerial minute to the secretary and no secretarial minute to the Minister could be confidential correspondence, if it is afterwards to be published in the House. I would invite the Minister to consider that.

That happened once before in connection, with the Department of Agriculture and I think the then Taoiseach indicated that he did not approve of the procedure, and it was never returned to subsequently. Perhaps the Minister would consider the propriety of reading out to this House a confidential memorandum which passed between a Minister and the permanent Secretary of a Department.

Mr. MacEntee

This is not a confidential memorandum, and the Leader of the Opposition will not get away with that. This is the record of a decision taken in relation to a programme which has been under discussion here——

Mr. T.F. O'Higgins

I have told the Minister that is not so.

Mr. MacEntee

——and, specifically, in relation to one item——

Mr. T.F. O'Higgins

Will the Minister accept from me that that is not so?

Mr. MacEntee

——which my predecessor claimed——

Mr. T.F. O'Higgins

Will the Minister accept from me that it is not so?

Mr. MacEntee

——claimed would have been proceeded with long ago if he had been Minister for Health.

Mr. T.F. O'Higgins

If the Minister has examined the records in his own Department, he knows the decision to which I came, namely, to postpone the regional hospital in Cork and to go ahead with the building of the new St. Vincent's Hospital in Dublin. The Minister knows that.

Mr. MacEntee

But I do not know.

Mr. T.F. O'Higgins

He should know.

Mr. MacEntee

When I came in, I found what had been decided, and what had been decided was as follows: the outgoing Minister had decided on 14th February, 1957, the middle of February, that he would defer any decision in regard to the two major projects. I have merely rebutted the statement made by Deputy O'Higgins that, had he been there as Minister for Health, certain projects would have proceeded. Now, I think Deputy O'Higgins acted correctly in asking the Secretary to record that decision. It was clear that there was going to be a change of administration. I appreciate the fact that he left the decision— and, of course, the burden and responsibility of making the decision—to me. It was the correct thing to do. With the Hospitals Trust Fund already hypothecated to meet old obligations, it would have been acting quite wrongly to have entered into a further major commitment, with the Fund in that condition and a change of administration in the offing. I do not want to go further than to say that I merely mention this fact to refute to the best of my ability, on the records available to me, the statement made by Deputy O'Higgins in criticism of me that, had he been Minister for Health, these particular projects would have gone ahead.

I do not wish to be querulous in answering the criticisms which have been made of myself, but I am, I think, entitled to take the strongest exception to the remarks which Deputy O'Higgins made in regard to the Board set up under the Opticians Act, 1956. Deputy O'Higgins, in the proper course of his responsibility under that Act, appointed four persons to the Board. I assume, in doing so, he consulted, in the way which seemed best to him, whatever organisation or body he considered suitable to advise him on the appointments. He had full discretion as to what bodies or organisations he would consult under the Act. So have I. He had full discretion, after consultation, to appoint four persons, each of whom had to be a registered medical practitioner.

I did not think that he had made a very good choice, not on personal grounds, but having regard to the functions of the Board under the Act. The persons whom he nominated were all resident in the city of Dublin. I thought that was a weakness, and I think I am perfectly entitled, in the exercise of my responsibility, to select these people according to a different system. I asked leading ophthalmologists resident in Dublin, in Cork and in Galway, and one other person, would they be prepared to act on the Board. One gentleman in Dublin whom I proposed to honour—that is the word— by asking him to act on this Board wrote back to me and said that, before accepting the invitation and saying whether or not he would act, he would have to consult his friends. Quite properly, I think, I said to myself that if he was not prepared to say "Yes" or "No" and has to seek advice as to whether or not he should co-operate in this public service, then I will not humiliate myself by asking the gentleman again, and I told him that I had withdrawn the invitation. The other ophthalmologists whom I invited to act, one residing in Galway and the other a surgeon practising in Cork, wrote back thanking me for the invitation and saying they were prepared to act.

Then I asked myself: What is the function of this Board? It is to ensure that a certain scientific standard and a certain standard of conduct will be required from those who practise as opticians. I said: "Let us see what is the scientific body which the Minister might, having regard to my view as to the functions of the Board, consult? I decided to consult the Irish Ophthalmological Society. It is a scientific body which includes in its membership all the leading ophthalmologists in the State——

Mr. T.F. O'Higgins

And some outside it.

Mr. MacEntee

Some from outside it. What harm? They live in this country. I regard them as Irish. I do not know what Deputy O'Higgins regards them as. They were not going to be asked to nominate anybody.

Mr. T.F. O'Higgins

They were going to be told.

Mr. MacEntee

No. What I required of them, and what I expected them to say, was whether, in their view, the persons whom I proposed to appoint to the Board were properly qualified professionally, and so competent to determine the questions of professional conduct and scientific competence which were the sole purposes for which the Board was being established. All credit to my predecessor for putting the Act through this House. I am perfectly certain he did not ask this House to pass an Act in order that he might constitute another trade union or another trade union congress. He said here at the time, quite properly, that the purpose he had in mind in asking the House to enact the legislation was to improve the standard of service given by Irish opticians.

I think I was perfectly justified in my endeavour to consult the body which I considered most suitable for my purpose. Just as Deputy O'Higgins, when he was Minister for Health, consulted another body. I accept that this was at his discretion; as it was his responsibility. I do not inherit, and I do not intend to inherit, all the misdeeds and mistakes of my predecessor, as I do not expect him to accept responsibility for any mistakes I may make. I am perfectly entitled to exercise the functions entrusted to me; and I am not to be told I am a little Hitler and a totalitarian when I am doing the job I was expected to do when I was designated as Minister for Health, when I am trying to do the job which the people of the country expect me to do, and that is to see that the health services provided by law, and the ancillary services for which my Department is responsible, are conducted and administered for the benefit of our people.

Therefore, the position in relation to this matter was that certain people met and they decided that they would not co-operate. They called on some people to resign; one did resign and another had a bereavement, and so on, but the Board is carrying on. I am quite willing to suggest other names to the body which I originally consulted and I am perfectly prepared, if I am allowed to exercise the functions reposed in me by the Oireachtas— functions which I discharge in virtue of the fact that I am supported by a majority of the elected representatives of the people for whom I act, and for whom I am trustee—to consult the Irish Ophthalmological Society. I am quite prepared to submit names to them for their observations, but I am not prepared to concede to them, or to any other organisation, the right of appointment which is vested in the Minister responsible to this House.

Deputy O'Higgins made the suggestion that if a certain notice, which is designed to have a certain effect, ceases to be published, I should be prepared to meet those responsible. Well, I would say this: as soon as the necessary conditions are established which would enable a meeting to be fruitful I am quite prepared to meet the representatives of the Irish Medical Association. However, I am sorry that in making that suggestion—I think it has been termed an olive branch—the Deputy put as many spikes upon it as would make it a blackthorn, because he clearly availed of the opportunity to try to put the responsibility for the present unhappy situation upon the Minister for Health.

I do not propose to enter into any lengthy controversy, and what I am saying now is not for the purpose of continuing that controversy but for the purpose of maintaining the correctness of the record and ensuring that no person who may afterwards read this debate—maybe the possibility is exceedingly remote—will for a moment accept the interpretation or the misrepresentations of Deputy Tom O'Higgins.

Mr. Dillon

My gracious!

Mr. MacEntee

Deputy O'Higgins relinquished office in March, 1957. During his term of office he declared the conditions for 13 posts. They were: surgeon to the Tipperary North Riding County Council surgeon to the Louth County Council, surgeon to the Wexford County Council, E.N.T.A. specialist to the Limerick County Council, ophthalmological surgeon to the Limerick County Council, paediatrician to the Galway County Council, E.N.T.A. specialist to the Galway County Council, paediatrician to the Limerick County Council, surgeon gynaecologist to the Galway County Council, surgeon to the Galway County Council, surgeon to the Kerry County Council, and surgeon to the Tipperary County Council. Each of these conditions, separately declared by my predecessor, contained the following statement of duties among others: "To give to any person being a registered medical practitioner authorised by the health authority or the Minister, when requested, the clinical details respecting any person who is or has been under his care in the hospital," and 13: "to give to the appropriate local authority all reasonable information respecting any person who is referred to him for examination and report by the local authority."

Those are the conditions which appeared in every declaration of conditions made by my predecessors. At the least they were acquiesced in, by the Irish Medical Association during the term that Deputy Tom O'Higgins acted as Minister for Health. I succeeded him and, before the end of the month in which I succeeded him, I received a letter from the Irish Medical Association objecting to these conditions which they had acquiesced in during the whole period that my predecessor had been in office. The letter objecting was, in fact, received on 27th March, 1957. In a reply to it, dated 1st April, 1957, I informed the Association that the draft represented the minimum necessary to enable the Minister and the health authorities to discharge effectively their obligations to the public. My predecessor, who attacked me in this debate, and I were in agreement about that. He had declared the condition. I accepted it. I thought, with him, that it was the minimum condition which it was essential should be one of the duties of the post, if we were to discharge our obligations effectively to the public.

However, my letter of April, 1957, went on to say that if the Association so wished the matters could be discussed at an informal meeting between a small deputation from the Association and the officials of the Department. It is important to note, in view of the statement that representatives of the I.M.A. have not been received by me, that a discussion took place on 31st May, 1957. In the course of that discussion it was freely admitted by the representatives of the I.M.A. that the problem was difficult. Certain proposals amending the declaration were discussed at that meeting.

The question was the subject of further correspondence culminating in a letter from the Association dated 8th November, 1957. I do not want to be controversial. I want to be as factual and as historically accurate as I can. On 31st May, a letter was issued by me and on 8th November, 1957, the proposals which were mooted as a result of that discussion were turned down by the I.M.A. I replied to that letter on 9th December, 1957. I heard nothing further beyond the bare acknowledgment of the letter from the Association until the ban was imposed—until this notice appeared in November, 1958, one year later.

It transpired from a letter which came into my possession that the reason for the publication of the notice was as follows. I think I had better read that letter for the sake of the record. It is headed 10 Fitzwilliam Place, Dublin, 2nd November, 1958, and it reads as follows:

In answer to your enquiry concerning the recent County Surgeons posts for Bantry, Laois, Monaghan and Sligo, the Executive Council of the I.M.A. at the request of the County Surgeons Group, examined the conditions of employment and salary scales offered. As a result of this examination the Executive Committee decided that the conditions and salary scales were unacceptable to the Association and, accordingly, advised members not to apply or if they had applied to withdraw.

1. The Council objected to Paragraph 13 and 14 of the Particulars of Office which were not acceptable on ethical grounds.

2. Para 2 (b) was considered contrary to Section 25 of the Health Act.

3. Salary was inadequate now that Section 15 is in force and in view of the New Health Bill before the Dáil (re raising the Middle Income Group level from £600— £800.)

I quote hereunder Paragraph 2 (b) and Paragraphs 13 and 14.

2 (b) The officer may act as consultant in a private capacity to another medical practitioner when such practitioner or the patient is resident in the functional area of the local authority, to such extent as, in the opinion of that authority, will not interfere with the efficient performance of his official duties but such private consultant practice may not be conducted in a health authority institution.

In respect of such private practice he may charge to the patient such fee as may be agreed between them; subject, however, in the case of his private patients in the hospital, to a maximum fee of 25 guineas.

13. To furnish the clinical details regarding any person who is or has been under his care in the hospital, to a registered medical practitioner authorised by the health authority or the Minister on request, on production of the written consent of the person (or the written consent of the person's next-of-kin) or, in the case of a registered medical practitioner authorised by the Minister, the Minister's certificate that it would not be in the public interest to seek such consent.

14. To give to the health authority all reasonable information respecting any person who is referred to him for examination and report.

Paragraphs 13 and 14 were the modified conditions of employment which I had submitted to the Association, they having rejected the conditions laid down by my predecessor, conditions which they had acquiesced in during all the period that he held office. Therefore, apparently what was all right when Deputy T.F. O'Higgins was Minister for Health quite suddenly became all wrong when Deputy Seán MacEntee became Minister for Health. I do not intend to do any more than to point out that fact. That it is a significant fact cannot be denied.

As I have shown, I had prolonged negotiations in relation to this matter. The discussions started in May, 1957. They culminated in two letters—one sent by me to the Medical Association which was rejected by them in November, 1957, and a further letter in reply to their rejection which I sent to them in December, 1957. No more was heard about this matter until this notice of a ban suddenly appeared.

In the letter I have read there is a reference to remuneration and it is stated the salary scales offered are unacceptable to the Association. Here is the position in relation to that matter. On 10th May, 1957, the Association wrote to the Department requesting a discussion at official level on the terms of service of county surgeons and what has since been described as the worsening of conditions following the implementation of the Health Act, 1953, which they stated brought the middle income group within the scope of the service provided.

On the 19th June, 1957, in reply to that letter, the Association was informed that these matters could more appropriately be discussed by the Association, in the first instance, with the Managers' Association. The Association suggested a tripartite conference between the Association, the Department and the managers. The Department, with my full concurrence —the matter was submitted to me for my decision—held the view that it would be more appropriate to have the discussion with the managers in the first instance. The Association agreed to this course and notified the Department accordingly on the 31st July, 1957.

The next discussion was held on the 12th June, 1958. I understand it was an amicable discussion and that the Irish Medical Association group, representing the county surgeons, undertook to prepare a further memorandum covering certain aspects of their claim and forward it to the Managers. This memorandum, however, never reached the managers. It had not been submitted to them when in the following November this notice which Deputy O'Higgins said annoyed me appeared.

The same thing happened a month later, in December, 1958, in relation to the post of county physician. I suppose what has happened since is sufficiently imprinted on the public memory not to need any further detailing. That is the position in regard to the dispute. That is how the cleavage originated and that is how the matter stands today as far as I am concerned.

I have done nothing to justify the action which the Irish Medical Association have taken—nothing whatever. I met them with courtesy. They have been on several occasions to my Department. The matters which they desired to discuss have been discussed in the Department. On occasion, indeed, I may say that my Department has been treated with some degree of discourtesy. It has happened more than once that the representatives of the Association who came to my Department have gone away undertaking to make fresh submissions to the Department and have failed to do so.

The Secretary, the senior officer of the Department during all this time, was the civil servant to whom glowing tributes were paid in this House the other day. In all these discussions you had representing me the former Secretary and the present Secretary—both responsible and experienced officials. They have all the minutiae of the services at their finger-tips. If a settlement can be reached on such matters as those I have been discussing, as it should be, a discussion with them would be much more satisfactory and much less time-consuming than a discussion with the Ministerial Head of the Department. I do not think one is justified in discussing sometimes trifling affairs with the representatives of various organisations when, in fact, the Dáil maintains highly-paid administrative officers to deal with these technical details. It is not true, therefore, to say that I, as Minister, have not been ready to have them received by high senior officers who are quite competent to deal with these matters.

Another point which Deputy O'Higgins made was that the public were in some way suffering because of this lack of contact between the Irish Medical Association and the Ministerial Head of the Department. I deny that absolutely. No persons have suffered in this country because of the publication of these notices except those professional men who have complied with the notice, who accepted the injunction which it was intended to convey and who failed to compete for certain official posts for which no doubt some of them would have been well qualified. They have suffered because the posts which an attempt was made to ban have been filled. I have not any doubt whatever that if other vacancies arise tomorrow we will be equally successful in filling them.

No patient, no person entitled to services under the Health Act, has suffered in any way by reason of what has arisen between me and the Irish Medical Association and no patient will suffer. I do not want to see the situation, continuing on that basis, however. When I first addressed the Irish Medical Association, as I did in Cork in 1957, I told them how anxious I was that there should be co-operation between us. That is still my attitude towards them, but let everybody make up their minds about this, so long as I am Minister for Health I am going to try to do my duty to the people and I am not going to allow myself to become manipulated like a marionette by those who have their own particular views in relation to many things with which I do not agree.

The Deputy accused me of getting people to approach county managers, to try to negotiate with county managers in relation to the conditions of employment affecting themselves. I have not done anything of the sort. It is quite clear, however, from what has been taking place over the past few months that, at last, regard is being paid by some people to the statutory conditions governing the employment of those who are in the health services of the local authorities. I have several times pointed out that county surgeons, county physicians, county medical officers and dispensary medical officers are not employees of the Minister. They are employed by the local health authority and the Local Government Act, 1955, clearly places upon the managers and clearly confers on the local health authority the right to conduct negotiations for the settlement of remuneration and conditions of employment.

That is the legal position, the statutory position. I am not going to regard the laws of this land as something to be lightly put aside merely because they are thought to be inconvenient or derogatory to the prestige or the status of anyone. The position is that, in fact, various groups have been meeting the county managers. I understand that the county surgeons met the county managers. I understand that the county physicians met the county managers; that the assistant medical officers' position has been discussed and that the local dispensary medical officers in the several counties have been meeting the county managers whom they serve.

Let me say this. The county managers are not meeting any one of these groups and have not met any one of these groups in their personal capacity. They are meeting them as representing the local authorities and the ratepayers who will eventually, with myself, have to meet the increased cost of whatever agreements may be arrived at. If there has been delay in asking local authorities to give effect to the agreements which have been hammered out —and I think it is all to the good that they should be hammered out on a national basis—it is because of the fact that the mandate of the local authorities was rapidly expiring and it was thought to be desirable that the new local authorities should have the first opportunity of considering the position. Certainly I have made no endeavour to influence the county managers and I know there has not been any unwillingness on the part of the county managers to consult their councils in due course.

The fact of the matter, however, is that in so far as the practical situation is concerned the attitude which the other party to this difference has seen fit to take up has been made ineffective; the posts have been filled, the statutory position in regard to the officers and in regard to the local authorities has been accepted and there is not any reason in my view why friendly relations cannot be resumed the moment I am satisfied that the Irish Medical Association is prepared to cooperate with me in trying to make the Health Acts work effectively and for the benefit of the people.

I do not want anybody to humiliate himself in any way. If the next issue of the Association's Journal ceases to carry a certain advertisement the way will be open for a meeting between myself as Minister and the representatives of the Irish Medical Association to try to establish better relations, relations which will be based upon a recognition of the rightful authority and responsibility of the Minister for Health, whoever he may be, to ensure that the services provided under the Health Acts are made readily, effectively and properly available to all those who are entitled to them. I hope it will be possible for us to reach agreement on that basis.

Mr. T.F. O'Higgins

Before the Estimate is put might I just ask the Minister whether he would not agree that the statement made by the President of the Irish Medical Association has made it more possible far co-operation between the Association and himself? Would he not at least concede that that is so and approach this problem in the light of that statement, perhaps to a more fruitful conclusion?

Mr. MacEntee

I must say that I read the statement of the President and I am sure it was well-intentioned. I know the President; he is an old friend of mine. I think that it failed to recognise the essentials of this position, that is, that I cannot agree to a meeting as long as there is published an intention by the Association of trying to prevent the Minister for Health from fulfilling his statutory duty to provide effective health services for all the people. I do not want to start discussing the merits and demerits of the advertisement again. As I said, there is no need for any member of the Association to make long speeches, or for anybody else to make them, and no need for any intermediary. The whole thing can be disposed of by refraining from taking action which is clearly intended to deter people from entering the health services.

Dáil Éireann debate -
Tuesday, 12 Jul 1960