Committee on Finance. - Vote 54—Health.

I move:

That a sum not exceeding £6,799,800 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, 1962, for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an Árd-Chláraitheora), and certain Services administered by that Office, including Grants to Local Authorities and Miscellaneous Grants.

As in previous years I propose to review briefly the more significant vital statistics for the preceding calendar year. The figures I quote are provisional but experience indicates that the final figures will not differ materially from them.

In 1960 there were more births, more marriages and less deaths than in 1959.

The number of births registered was 60,730, an increase of 542 on the previous year. The rate, at 21.4 per 1,000 population, was again appreciably higher than in neighbouring countries. In England and Wales the figure was 17.1 and in Scotland 19.4.

The number of marriages in 1960 was 15,494, an increase of 74 on 1959.

The number of deaths was 32,660, a decrease of 1,585.

There has been a steady downward trend during the past decade in the death rate from tuberculosis. The trend continued in 1960 and the number of deaths from all forms of the disease fell to a record low figure of 468, which was 49 fewer than in the previous year. Equivalent to a rate of 17 per 100,000 of the population, the mortality from the disease in 1960 was in striking contrast with the position in 1950, when the death rate was almost five times as high. The figures for incidence also fell, the number of new and reactivated cases in 1960 being 3,478 compared with 4,344 in 1959. Such progress is encouraging; but the fact that so many new cases occur each year shows that a large pool of infection still exists. This is disquieting, as it indicates that the measures for the prevention and early diagnosis of the disease which are ready to hand are not being availed of as widely as they ought to be. I should emphasise that this is especially the case with B.C.G. vaccination and mass-radiography.

Experience has established that B.C.G vaccination is particularly valuable in the case of young persons who leave rural areas to work in towns and cities as many country-born children eventually do. Yet the latest figures available, though they are an all time record, show that many of them do not yet realise that this easily-acquired protection, which can be the means of preventing grave illness, is there for the asking and should be fully availed of. Mass-radiography is aimed primarily at detecting tuberculosis in the early stages when treatment is likely to be most effective. It offers to all, old as well as young, a necessary check upon lung and other respiratory and chest conditions. Yet in 1960 only about 10 per cent of the population came forward for X-ray. This is far from satisfactory. The ideal would be that everyone should undergo this simple check-up once a year. Perhaps this ideal will never be attained, but if it were, it is certain that probably the vast majority of us would emerge from the check with a clean bill, so far as tuberculosis is concerned. The ascertained fact, however, is that 3 per thousand of those who undergo this check-up are shown to be suffering from the disease in a more or less active from and the question arises—who knows which of us comes within that category? The answer is none of us who has not submitted himself to an X-ray during the year and secured a clean bill on the test. That only 0.3 per cent of those who have themselves X-rayed should be found to be infected indicates that for the vast majority the outcome of an X-ray examination is likely to be highly satisfactory and most re-assuring. And even for the few who are warned that they require immediate medical attention the outlook is not too gloomy; for the community will come to their aid in the most practical way. First of all since T.B. is an infectious disease, medical attention and treatment, whether in the home or a sanatorium, is given free of charge. Secondly, subsistence allowances are granted where necessary in respect of a dependent spouse and children. No person, therefore, need be deterred by financial considerations from availing himself of the mass-radiography service. The service indeed may well save his life, since, if an infective condition should be detected by it, all the health services are available to the individual concerned and will afford him the latest and most effective treatment. Moreover, the X-ray may detect other unsuspected conditions, conditions possibly, which may yield to treatment at an early stage, but which, if neglected may prove intractable. In short, the minutes spent in having an X-ray may purchase many years of life.

But, of course, tuberculosis, though still a significant killer and highly important because it is infective, is by no means the most lethal of the conditions with which modern society has to cope. Last year cardio-vascular diseases and cancer were again the two major killing diseases. The former in fact, was responsible for 10,633 deaths, as against 10,830 in 1959—by no means a notable decline. In the case of cancer, unfortunately the decrease was scarcely apparent, the overall mortality at 4,759 being only 18 deaths lower than in the previous year. While the mortality figures for these diseases are consistent with the prevailing world pattern, the picture, so far as cancer goes, would have been a little brighter, had it not been for the fact that the number of deaths from those forms of it which are grouped under the title of lung cancer, showed a significant increase from 601 in 1959 to 648 in 1960. Since there is abundant evidence of a correlation between heavy cigarette smoking and death from lung cancer, the figures for cancer deaths carry a grave warning to all who smoke.

With maternal and infant mortality, our experience has been much better and the rates have continued to fall. The maternal mortality rate was 0.58 per 1,000 births, as against 0.65 the previous year, while the infant mortality rate was 29 per 1,000 live births as against 32. This continuing improvement is heartening. It is especially so when allowance is made for the pattern of late marriages and large families in this country. Nevertheless, figures for neighbouring states indicate that further improvement is possible. Thus, in 1960, the maternal mortality rate in England and Wales was 0.4; in Scotland it was 0.3; and in Northern Ireland it was 0.4. The infant mortality rates in these areas were: England and Wales, 22; Scotland, 26, Northern Ireland, 27.

The most dangerous period in the life of an infant is what is known as the peri-natal period, extending from the 28th week of gestation to the end of the first seven days of life. This fact was emphasised by a study published some years ago by the World Health Organisation. The study showed that, while infant mortality in general has decreased sharply, mortality at birth has not decreased to anything like the same extent. In addition, the study indicated that almost a third of peri-natal deaths occur on the day of birth; that the death rate is considerably higher for boys than for girls, but that far more girls than boys die of congenital malformations of the nervous system. The reasons for all this are not yet clear, and the fact that a high percentage of peri-natal deaths listed in the study were described as being due to "ill-defined or unspecified causes" went to show that much has yet to be learned about the problem.

About six years ago, the World Health Organisation invited Ireland, Sweden and the Netherlands to undertake a special survey as an initial step towards determining what action could be taken to reduce this peri-natal mortality. All three countries agreed to accept the invitation; and, on my immediate predecessor's invitation, the Medical Research Council agreed to conduct the survey here. I am glad to say that the work has been proceeding very satisfactorily and that it is anticipated that results will be available for analysis this year. It is impossible to say, of course, what contribution the work will make towards a reduction in the number of deaths in future, but I know that every member of the House will agree with me that participation in pieces of research such as this, well thought out and carried through on an international scale, is worth while and will join with me in thanking the Medical Research Council for its ready co-operation.

Turning to the communicable diseases, we find that deaths from poliomyelitis rose from 2 to 17. The number of cases of this disease noted in 1960 was 183. As the House is aware, a vaccination service which gives a high degree of protection against it has been in operation since April, 1957. Its scope has been widened every year since then, and in the current year is being widened still further.

The service now provided by health authorities is available to persons in the lower and middle income groups between the ages of 6 months and 40 years, to expectant mothers in those income groups and to other special categories. These include hospital staffs, certain practising nurses, medical and dental students, teachers, and other public health staff who might come into contact with poliomyelitis cases, together with the families of persons in these groups. The service is free of charge to persons in the lower income group and the special categories mentioned. For those in the middle income group, outside the special categories for which, as I have stated, it is free, reasonably small charges are made. Provision is also being made for a fourth injection where appropriate. In view of the wide coverage which the service now offers, there is no reason whatever why anyone should take the risk of contracting "polio" rather than be vaccinated against it.

I cannot be too strong in urging everybody to avail of the several vaccination and immunisation services which their local health authority provides, not only against poliomyelitis, but against diphtheria and small-pox. It is true that we have had no case of small-pox for many years and that the incidence of diphtheria has declined considerably and this may be the reason why the number of persons who have taken the precaution of protecting themselves against these diseases is disappointingly small. Prophylactic safeguards against the risk of contracting these diseases are available free of charge to everyone without exception, and yet they are not being generally availed of. Such lethargy is not only disappointing, it increases the risk that, should one or two cases occur and remain for even a relatively short time undetected, a very grave and widespread situation may develop with great rapidity.

To turn now to the Estimate itself, the largest single item is that included under subhead G—which provides for a total of slightly over £9,000,000 in grants to local health authorities in aid of their expenditure on health services. These grants are authorised under the Health Services (Financial Provisions) Act, 1947, the effect of which, nowadays, is broadly to commit the State to meet half the cost of local health services.

The total cost of these services in the present year, having made allowance for such receipts as charges on patients, will be about £18 million. This compares with £17.6 million last year, and £16.8 million in the year to 31st March, 1960. The corresponding totals for 1953/54, the last complete financial year prior to the partial introduction of extended health services under the Health Act, 1953, and for 1956/57, the first complete year after the introduction of the services, were £11.2 million and £15.8 million respectively. While there was thus a definite increase in the cost of the health services in the period immediately following the coming into operation of the 1953 Act, and while the cost has continued to increase more gradually since, the whole of this increase cannot be attributed to the Health Act. Not by any means.

Quite a substantial factor has been the making good of regrettable deficiencies in our health services, deficiencies which common humanity demanded should be remedied, Health Act or no Health Act, as rapidly as possible. The increased facilities which have been provided for the care and treatment of mentally-handicapped children is an example of this. In 1953 there were 1,460 beds for such children. This year we have 2,734 and it is hoped to bring this figure up to 3,000 by 1963-64. Not only has the capital cost of these additional beds been met almost entirely from the Hospitals Trust Fund, but the greater portion of the actual cost of maintaining the children is covered by the capitation grants paid by local health authorities, who are in turn recouped as to one-half of their expenditure from moneys provided under this Vote. Thus the cost of caring for these young patients is borne almost completely by the ratepayers and taxpayers, and is increasing from year to year.

In 1953 the capitation rates payable to these institutions were generally in the region of £2 5s. Od. per week and were payable in respect of about 1,400 children. To-day they vary between £3 10s. Od. and £4 per week, and are payable in respect of about 2,400 children. In 1953 the cost of this service was of the order of £190,000; to-day it is in the neighbourhood of £450,000, perhaps even more. It will almost certainly be more next year and more still as time goes on. But what are we to do about it? Who of our critics will tell us to call a halt in dealing with this problem? Are they not urging us to spend more and more money to solve it?

Expenditure on drugs and medicines used in our mental hospitals during 1953/54 was £25,000. This year it will probably be £122,600, which is quite a considerable increase. But the increase is spent in the main on newly-evolved drugs, most of them drugs the established therapeutic value of which is high, the drugs which give so much relief to the mentally disturbed. Thanks to them the whole approach to mental illness has been altered. There is now hope in most cases, if not always a complete cure, at least a marked alleviation of suffering. Thanks to them also the general atmosphere of our mental hospitals has changed. Their patients are more peaceful, calmer, and less fractious than they used to be. But the drugs which have brought all this about are expensive; they increase the cost of the services, and accordingly they send up the rates. But is there any Deputy who is prepared to urge that for these reasons we should cease to buy them, cease to use them, and turn our now peaceful and curative mental hospitals back again into the bedlams they once were?

Apart from increases of this nature, originating in a fuller recognition of the obligations which the community in general has towards its more hapless members, account must also be taken of the undeniable fact that the rates of remuneration enjoyed by the personnel of the service have been substantially increased. This increase is in no way peculiar to the health services or ascribable to the operation of the Health Acts. To the extent to which the increases are not represented by an actual rise in living standards, they are a reflection of the fact that, throughout the world, there has been a significant fall in the value of money. To obtain a true picture of the increase in expenditure which can be attributed solely to the growth of health services as such, it would be necessary to eliminate these factors. This would entail breaking down an intricate cost complex into its elements. In view of the fact that the final result would be of no practical utility whatsoever, it would be futile to waste time and money on such a task. There is, moreover, a better and more realistic way of approaching the problem available to us.

The relation which the amount expended from public funds on a particular service in any year bears to the gross national product in that year is a measure of the real burden which the service in question imposes on the community. Applying this standard to our expenditure on the health services since 1953, a picture, and it is a true picture, emerges which will confound our critics —that is so far as costs are concerned. The percentage of the gross national product represented by the amount of central and local taxation required to pay for health services in 1953 was 2.14. This proportion has risen to 2.92 in 1956 but by 1958 had declined to 2.77. In 1959 the percentage was 2.70 and it is estimated to be 2.71 for 1960. It would seem therefore, that not only has equilibrium been reached in the proportion of the national product spent through rates and taxes on health services, but that in relation to the capacity of the community to pay for them, the cost of the health services tends to decrease. This is as one would expect in a prospering community.

During the past year there have been statements to the effect that the additional services provided under the Health Act, 1953 are now costing the ratepayers considerably more than had been forecast in 1952 when the Bill was under discussion. Recently in this House, a figure of 8/- in the £ was mentioned as the amount of the increase. I am referring to the Dáil Debates of 14 March, 1961, Column 550. In arriving at this conclusion, Deputy Thaddeus Lynch, who postulated that figure, appears to have overlooked the significance of certain administrative changes brought about by the Health Act, 1953.

Prior to the coming into operation of that Act, local authorities in their capacity as public assistance authorities provided a wide variety of health services and the cost of these was shown in the rate demands, as well as in the rating returns and the accounts, as public assistance expenditure. The services thus scheduled as public assistance services included such major items as the dispensary service, general hospital services and the county home services —all of which are undeniably health services, and nothing else but health services. On the other hand the medical services provided by local authorities, as health authorities, were limited to such services as school health inspection and control of infectious diseases —that is, to a very restricted range of special activities. But prior to the coming into operation of the Health Act, 1953, it was only the expenditure on such services which was classified as health expenditure and defrayed from the "health" rate.

The 1953 Act rationalised this absurd classification so that expenditure on services which were in fact health services, though previously included under the head of public assistance, was thenceforth debited to the health account. Consequently a comparison of the "health" rate for a year prior to 1954 with the "health" rate in later years is invalid. If it is sought to obtain a realistic picture of the rate position in any year it is necessary to bulk the "public assistance" rate with the "health" rate proper. If this is done it will be found that, in the counties, the average increase in the rates between 1953-54 and 1960-61 was just under 3s. in the £. Not all of this increase was due to the improvement and expansion of existing services or the introduction of new ones. I have already shown indeed that a substantial fraction of it has been generated by a wholly adventitious factor, to wit, the decline in the value of money.

In the county boroughs, the average increase corresponding to the figure of just under 3s. for county areas was 5s. in the £, and here again a substantial portion of the increase has been due to the same factor, one which is completely extraneous to the Health Acts. A rough estimation shows that about half of the increase could be ascribed to this and other adventitious factors. When, therefore, allowance is made for such factors, as it must be made, the average real increase in rates which may be attributed to the improvement and expansion of the health services since 1953 is not 3s. in the counties and 5s. in the county boroughs, but only 1s. 6d. and 2s. 6d. respectively.

The figures which I have given are average figures, taken over all the counties in the one case and over all the county boroughs in the other. To bring home the point in concrete terms, however, I shall take as examples, the cases of typical farmers in Limerick, Kildare and Monaghan, assuming that in each case the valuation of the farm is £30 and that one agricultural labourer is employed.

In the year 1953/54, the rate in Limerick County in respect of health charges, including mental hospitals and all public assistance charges, the most of the latter being, as I have pointed out, medical in character, was 8/1d. in the £. The gross amount of rates payable by our Limerick farmer in respect of these services would thus have been £12 2s. 6d.—if account were not taken of the allowances payable by way of Agricultural Grant. In fact, these allowances reduced the impost on this Limerick farmer by £8 17s. 8d., and left the net sum of only £3 4s. 10d. as the amount which he was required to pay in rates in respect of the financial year 1953/54 to meet the cost of all health and public assistance services, including medical services, provided by his local authority.

For the farmer in Kildare with a £30 holding, the corresponding amounts for that same year of 1953/54 were £14 17s. 6d. gross and £3 19s. 4d. net. For the farmer in Monaghan, the figures were £11 10s. 0d. gross and £3 1s. 4d. net.

Now let us turn to the year 1960/61 and see what the increase was in terms of the actual cash payments which would fall to be made by these three farmers. For the farmer in Limerick, the total rate in respect of health and public assistance charges had risen to 11/11d. in the £, that is, by more than the national average and the gross amount of rates payable by him to meet these charges had risen to £17 17s. 6d. Again, however, when account is taken of the allowances payable by way of Agricultural Grant the actual charge falls to be reduced considerably, the amount of the reduction being £13 0s. 5d. This leaves a net amount of £4 17s. 1d. payable. Accordingly, the actual amount of rates which this farmer is called upon to pay for health and public assistance charges in 1960/61 is £4 17s. 1d. as compared with £3 4s. 10d. in 1953/54, representing an increase of only £1 12s. 3d., in return for which he becomes entitled to the benefit of the extended services under the 1953 Act for himself and his family.

For the farmer in Kildare, the corresponding increase is £2 1s. 10d., being the difference between the net amount of £3 19s. 4d. payable in 1953/54 and the net amount, £6 1s. 2d., payable in 1960/61. In the case of the Monaghan farmer, the increase in the rates actually payable is £2 1s. Od. which is the difference between £3 1s. 4d. net in 1953/54 and £5 2s. 4d. net in 1960/61.

Incidentally, averaging the increase in the amount which would be payable in 1960/61 as against 1953/54 in these three cases, we find that it represents no more than 38/4d. over the seven year period. This is equivalent to an increase of 15?d. in the £, which is a long way from the 8/- postulated by Deputy Thaddeus Lynch.

Furthermore, all of this 38/4d. is not properly chargeable against the 1953 Health Act. A substantial portion of it, perhaps even half of it, has been engendered by influences, like inflation, which have operated to increase the cost, not merely of the health services, but of every commodity and of every service, whether it be health, transport, education, food, clothing, entertainment or otherwise. Making allowance for the effect of this all-pervading and predominant factor, it cannot be contended by any reasonable person that over the whole seven years the increase in rates payable in respect of a residential holding of £30 valuation, and properly attributable to the operation of the 1953 Health Act, amounted to more than £1 per year.

The remaining subheads of the Estimate show little change compared with last year and, apart from Subhead N on which I will speak later, do not call for any detailed comment. I may say though that the increase under Subhead A is accounted for by an addition to the medical staff of my Department to bring it up to the authorised full strength and by the general salary increases. The increase under Subhead F is due mainly to provision for the cost of the Commission of Inquiry on Mental Handicap, to which I shall refer later.

With regard to Subhead M, I referred last year to the purpose of the provision of £3,000 then made under this subhead, namely for obtaining advice and assistance on the establishment of a rehabilitation centre. Progress with the formulation of the necessary scheme was not as rapid as had been anticipated and consequently the provision was not utilised. It is repeated this year, and with the establishment of the National Medical Rehabilitation Centre at Our Lady of Lourdes Hospital, Dún Laoghaire —a matter to which I will refer later —the expenditure of the allocation in the current financial year may now be anticipated. An allocation of £1,000 was also made under the Grant Counterpart Agreement with the United States for the study of methods for the diagnosis, prevention and cure of pneumoconiosis in mine workers. Provision to spend this is included in this year's Estimate. Expenditure from the subhead will be recouped from the American Grant Counterpart Special Account and provision has been included in the Appropriation-in-Aid Subhead for a receipt of a similar amount to that referred to above, namely, £4,000.

The fact that liquidity has been restored to the Hospitals Trust Fund has enabled me to authorise the resumption of hospital building on a number of projects. Among these is the new Erinville Maternity Hospital in Cork, on which work is now in progress. This hospital will provide accommodation for 54 maternity and gynaecology patients and a neo-natal unit of 14 cots. A new nurses' home is in course of construction at Portiuncula Hospital, Ballinasloe. Special attention is being directed to the improvement of conditions in mental hospitals and among the more important projects commenced is a new 60-bed admission unit at Cork Mental Hospital. Work has also started on a scheme for the improvement of the water supply and the provision of central heating and new sanitary annexes at Clonmel Mental Hospital. Contracts are on the point of being placed for the building of extensions at the Home and School of the Immaculate Conception, Cregg House, Sligo, which caters for female mentally handicapped persons. This project will provide 143 beds.

Planning has almost been completed and it is expected that tenders will be invited in the near future for the building of extensions at St. Mary's Convent, South Hill, Delvin, where mentally handicapped persons are also cared for. This scheme envisages the provision of 120 beds. Work is also well under way on a building to house the cobalt therapy unit at St. Luke's Hospital, Dublin. This form of treatment has not up to now been available here for patients suffering from cancer. A specially equipped and staffed radioisotope unit is also being provided at St. Luke's Hospital which in addition to catering for the needs of the hospital, will also provide a service for other hospitals requiring it. The total cost of the projects which I have mentioned is estimated at £830,000; and all of them, provided nothing extraordinary occurs, will be carried through to completion.

Among the major voluntary hospital schemes to which approval was given in the past year was the resumption of work on the new St. Vincent's Hospital at Elm Park. This will be a teaching hospital and will, therefore, be a most important addition to the hospital services in the Dublin area. A grant of £1,500,000 has been promised for the project and planning work in connection with the superstructure is now in progress.

I am happy to report that good progress is being made in planning the new Coombe Hospital and present indications are that it should be possible to commence building operations next year.

Other works approved in principle at voluntary hospitals include the provision of accommodation for nurses at the North Charitable Infirmary, Cork, improvements in the accommodation at Cork Dental School, a new theatre suite and the renewal of the electrical installations generally at Jervis Street Hospital, and the reconstruction of premises at the National Children's Hospital, Harcourt Street, to provide accommodation for nursing staff. A scheme for the extension of accommodation at St. Vincent's, Lisnagry, County Limerick, will provide additional facilities for the care of female mentally handicapped persons. The carrying out of improvements at St. Teresa's Home for Girls, Blackrock, County Dublin, where similar patients are cared for, has also been approved.

On the local authority side, particular emphasis has been placed on improving the conditions in mental hospitals and county homes. A short list of urgent works at mental hospitals has been drawn up and considerable progress in planning has been achieved. The gross cost of the works involved is estimated at about £1,000,000. I confidently expect that work on a number of these projects will start this year. The decision, to which I referred last year, to press ahead with the planning of comprehensive schemes of improvement in the county homes is being implemented with all possible speed. Due, however, to the complex problems involved, and the very extensive nature of the work required, the planning is taking somewhat longer than I had expected. This programme for the improvement of standards in the county homes is not being assisted by the Hospitals Trust Fund but, in accordance with a decision taken in September, 1951, will be financed from the Local Loans Fund. Half of the loan charges, however, will be recouped to the local authorities concerned from the Vote for my Department.

Among the more important works at local authority general hospitals which I approved during the past year and which are now being planned, are a scheme of improvements at the County Hospital, Wexford, and the provision of additional beds at Sligo County Hospital, including a sub-regional ear, nose and throat unit.

There is an important aspect of hospital building to which, I feel, I should refer—that of the need for proper maintenance. It is a matter which, unfortunately, has not received due attention from health authorities in the past. The seriousness of it has been highlighted for me by recent cases of neglect, extending over many years, on the part of local authorities in relation to their mental hospital buildings. The result of this continued lack of maintenance of the fabric of these buildings is that the unfortunate ratepayers of the areas concerned will now be faced with a heavy bill to remedy the widespread serious structural defects which neglect has allowed to develop. The old adage "a stitch in time saves nine" is surely apposite here.

Many of our health institutions, notably the mental hospitals and county homes, were built in the last century. It should be obvious to the controlling authorities that, in such cases particularly, periodic inspection of the buildings and prompt attention to defects are vitally important for their proper preservation and for the comfort of the patients and staff housed in them. Furthermore, there has been a capital investment during the last thirty years of many millions, mainly from the Hospitals Trust Fund, on new local authority hospitals. It is an obvious and essential part of the obligations of health authorities to see that these new hospitals are kept in a proper state of repair, and thus ensure that no part of these vital capital assets will be lost for the want of necessary maintenance.

I have asked my Department to examine this general problem, so that everything proper will be done to make certain that health authorities regularly and effectively will inspect all their institutions and operate a systematic maintenance procedure whereby structural defects will be remedied without delay. Henceforth an effective check will be kept on the manner in which health authorities are fulfilling their obligations in this matter.

The hospital treatment of tuberculosis does not now make the same demands on our resources as in recent times, so that the available accomodation is substantially in excess of needs. Steps are being taken to use for other health purposes those of the redundant sanatoria which can be adapted economically to such purposes. During the past year, the reallocation of surplus tuberculosis accommodation brought a measure of relief to overcrowding in the mental hospitals. The former sanatorium at Ballyowen, County Dublin, has now been opened for the treatment of acutely ill female mental patients. The former sanatoria at Shaen, County Laois, and at Listowel, County Kerry, were taken over to make room for some of the patients accommodated in overcrowded conditions at the mental hospitals at Portlaoise and Killarney.

Because of certain difficulties in securing trained and experienced personnel, I have not been able to utilise Woodlands, in County Galway, as I had hoped. Portion of it, however, is now being used for the purposes of a new industrial undertaking, pending the erection of its own factory.

In the field of mental health a Commission of Inquiry is now investigating the problem of mental handicap, and I hope in the very near future to announce the establishment of another, which will concern itself with mental illness. These two Commissions are complementary and between them they will cover all aspects of the mental health services. It will give some idea of the magnitude of their task when I say that the mentally ill and mentally handicapped occupy nearly as many places in hospitals as do all those treated for physical ailments.

The main problems associated with the provision of a service for the mentally handicapped were set out in a White Paper which was published in 1960. Very briefly they are: the organisation of services for the ascertainment and assessment of the degree of mental handicap; the establishment of domiciliary and out-patient services; the provision of appropriate institutional accommodation for those needing it; the organisation of an aftercare service; the provision of training and placing in employment of suitable persons; and last but by no means least, the recruitment of adequate trained personnel to provide the necessary services.

These are formidable problems, and, inevitably, an attack upon them will cost a considerable amount of money. As I have previously emphasised, I regard it as essential that our services should be well conceived, well planned and calculated to yield the best results to those for whom they are provided, so that there will be no wastage of time, money or effort on haphazard, ill-considered, or non-productive developments. In drawing up the terms of reference of the Commission free to advise me on every aspect of the care of those thus afflicted, to report objectively on our services as they exist and to recommend such changes as it considers desirable. Pending the report of the Commission all possible steps to supply obvious needs will be taken. At the moment we have accommodation in residential institutions for 2,734 patients, and when the works now about to commence are completed, we shall then have about 3,000 places.

The terms of reference of the Commission on Mental Illness have similarly been drawn to permit the Commission to examines all the problems involved with the utmost objectivity. I wish to assure the House, though, that any improvements in the facilities for mental treatment, which are obviously necessary and which can be made meantime, will be carried out without waiting for the Commission's report.

During the past year a small reduction of 143 in the number of patients in mental hospitals was achieved. Overcrowding in our district mental hospitals and auxiliary institutions is still, however, a major problem.

I have already mentioned two of the ways in which we are seeking to alleviate it—new building within the mental hospitals and the utilisation of redundant sanatoria accommodation. Even in advance of the report of the Commission on Mental Illness, I hope and trust that the ultimate solution will not be found along those lines. Indeed, as a layman, I feel quite certain that, in the future, treatment services will be developed outside the mental hospitals; whereby it will be made possible to discharge patients, under suitable conditions, at an earlier stage than at present.

An interesting proposal made during the year and one to which I was happy to accord approval was the establishment of two day-hospitals, serving the towns of Monaghan and Cavan and the countryside immediately surrounding them. The Monaghan unit should be operating in the near future. The Cavan unit will come later. I am sure that the House will appreciate the importance of these developments. Under them a patient who attends at a day hospital will have the benefit of the full range of therapeutic facilities ordinarily available only to hospital in-patients, but will also remain in contact with his family and his normal environment. In this way he can avoid the sometimes painful process of rehabilitation and readjustment which is the lot of the in-patient on discharge from a residential institution. Moreover from the point of view of expenditure on health services, the day hospital offers considerable advantages. Less accommodation is required, and nursing and other costs are lower. But needless to say I want the House to understand that this is the merest secondary consideration.

I do not wish to overstress the importance of this development—many conditions of mental illness cannot, for instance, be dealt with in such hospitals—but I think the House will join with me in congratulating the Cavan-Monaghan Mental Health Board and its staff on the initiative they have shown.

A notable step forward in the organisation of rehabilitation services has been taken with the recent opening of the National Medical Rehabilitation Centre at Our Lady of Lourdes Hospital, Dún Laoghaire. This centre will be operated by the Sisters of Mercy, in collaboration with the National Organisation for Rehabilitation. Certain building works will be necessary in order to better adapt the hospital to its new purpose, and I have indicated that a grant from the Hospitals Trust Fund will be made to meet the cost of an approved scheme. I should like to take this opportunity to pay tribute to the combination of effort by these two organisations which is producing a more effective and economical result than could otherwise have been achieved. Another new development in this field is the recent opening by the Irish Sisters of Chairty of an outpatients' clinic planned to provide a range of rehabilitation services at St. Anthony's, Merrion.

In singling out for special mention the work of these bodies, I am not unmindful of the very valuable public service given by other voluntary bodies, great and small, throughout the country which have been operating rehabilitation services, perhaps in narrower fields, for some years past. They have, by their efforts, put the community very greatly in their debt. There is, however, an element of danger in such effort if it is not co-ordinated. Overlapping of activities could lead to waste of effort and money, and to frustration. The prevention of such overlapping and the achievement of co-ordination without regimentation was one of the objects which my immediate predecessor, Deputy T. F. O'Higgins, had in mind when he established the officially-appointed National Organisation for Rehabilitation. I have decided, as a matter of settled policy on my part, that before official support can be given to the establishment or development of any rehabilitation project, the advice of the Organisation will be sought. I have no doubt that such advice from that objective and broadly-based body will be of the greatest value to me, to future Ministers for Health and to the various groups operating in this field.

I should like to mention a few points in connection with the operation of what are known officially as the General Medical Services. Due to the extensive press publicity given to them at the time, Deputies are doubtless aware that in certain cases fees were accepted by dispensary doctors from persons who were entitled to general practitioner services free of charge, and of the action I felt compelled to take.

A district medical officer, that is to say a dispensary doctor, when he accepts one of these much sought after appointments enters into a solemn contract with the health authority, in consideration for the payment of a salary, to provide, to the best of his professional ability and without charge, for every person in his district determined by the health authority by the issue of a medical card to be so entitled, a comprehensive general practitioner medical service at the officially appointed dispensary at the officially appointed time, or at the patient's home if he is unable, because of his illness, to travel to the dispensary. Consequently, deliberate failure to give prompt and adequate attention, the conscious creation by his actions of the feeling that a better or more prompt service would be given if a payment were made, a demand for a fee or the acceptance of a fee or other reward, constitutes a breach of the obligations to the patient and to the health authority into which he entered voluntarily in accepting appointment.

I believe that the attitude of the very large majority of dispensary doctors towards their eligible patients is above reproach, but, if a dispensary doctor is so callous as to exploit the need of a poor person who is without means to engage a private doctor, then I am certain that Dáil Éireann would not expect me or any other Minister for Health to tolerate such exploitation. I feel confident that the House will, accordingly, endorse the warning which I now give that lack of proper attention to eligible patients or the demanding or acceptance of fees from them, will be dealt with most severely. Health authorities have recently granted a liberal increase in salary to district medical officers so that the argument, invalid though it always was, that dispensary doctors were entitled to accept fees because their salary was inadequate has even less substance than it had before.

Experience of the operation of dispensary medical services has shown the need from time to time for the revision of dispensary districts in various areas, but more especially in urban centres, in order to improve the standard of services in those areas, by, for example, affording relief to district medical officers, responsible for the care of an excessive number of eligible persons, or by allowing the attendance of eligible persons at more convenient centres. During the past year certain dispensary districts in the Dublin, Limerick city and Cobh areas were altered in this way. Major revisions are also under consideration in Cork city and suburbs, Galway, Kildare and a number of other health authority areas.

In dealing with such revisions in the larger urban areas I have thought it wise to depart, where possible, from the rather rigid sub-divisions of such areas previously in operation. Instead, it is intended where appropriate to have one dispensary district embracing the whole urban area. Duties can then be allocated to an appropriate number of district medical officers in the dispensary district, each one being assigned a sub-division of the district. This arrangement will be more flexible, as the sub-divisions may be varied administratively by the manager, with the consent of the Minister. It will allow the health authority to deal speedily with problems arising out of shifts of population within the urban area.

Under an Age Limits Declaration made in January, 1960, the retiring age of 70 was fixed for dispensary doctors, to operate from 1st July, 1960. The age limit for other officers in the local authority services is 65. Following representations made to me, by individual dispensary doctors and by groups of such doctors, in which the unusual nature of the position of dispensary doctors was stressed, I took measures to ease the effect of the Declaration in certain respects.

These measures included the postponement of the operation of the Declaration from 1st July, 1960 to 1st January last, the raising of the age limit for dispensary doctors who had reached the age of 67 years on 1st August 1960, to 72 and the fixing of an age limit between 70 and 72 for those between 65 and 67 on 1st August, 1960. In addition, I arranged that dispensary doctors may, when they retire from their permanent posts under the revised age limits as thus fixed, be in some cases retained in a temporary capacity for a while.

These concessions ensured that no dispensary doctor would have to retire without having a reasonable period in which to prepare for retirement. However, it was also represented to me that, these doctors being part-time officers, their pension compensates only for the loss of official emoluments and makes no provision for loss of private practice or disturbance of residence following upon retirement. This could constitute a hardship on officers who could previously expect that they might continue in office until death or voluntary retirement. To alleviate such hardship it is proposed, under Subhead N of the Vote, to make special compensatory payments to dispensary doctors retiring under the age-limit order within seven years of its commencement. The payments will take the form of a supplement to the pension payable by the health authority, varying in amount from 50 per cent. of the pension for those retiring this year down to 10 per cent. for those retiring in 1967. In all cases payment of the supplement will cease to be paid six years after the doctor's retirement.

In addition, to compensate for loss of the use of official dispensary residences, it is intended to make lump sum payments varying from £500 for those retiring in the year ending on before 1st July next, down to £100 for those retiring in the year ending on 30th June, 1965. This part of the scheme of compensation will cease to operate on that date. The estimated cost in the present year of supplements to pensions is £7,100 and that of the lump sum payments is £3,900.

These supplements and lump sums will fall finally on the Exchequer; health authorities will not be required to meet any portion of them. Any necessary statutory provision will be included in a forthcoming superannuation Bill; but in the meantime, I am anxious that the doctors concerned should not remain out of their money and consequently, if the House agrees, I propose to authorise payment as soon as possible after the Estimate has been taken. For that purpose, I am asking that the Estimate should be reported immediately after it has been passed in Committee. I should be grateful for the co-operation of Deputies in this matter.

There have been references from time to time to the desirability of providing a choice of doctor for persons eligible for the general medical service, by substituting for the dispensary service a panel scheme for persons in the lower income group. This question was examined in my Department as far back as 1953, when Deputy Dr. Ryan was Minister for Health. It also received the close attention of Deputy T. F. O'Higgins when he was Minister. I also have considered it very carefully. Apart, however, from the important question of extra cost, and the burden which this would impose, particularly on the rates, there are practical difficulties and disadvantages in this proposal which cannot be ignored.

The establishment of a panel scheme pre-supposes the abolition of the dispensary system in its present form and the remuneration of participating doctors on a capitation basis. This, of course, would constitute something of a major revolution. Apart from this, a highly practical consideration is the fact that in many of the rural areas—indeed in substantially more than one-half of the total number of dispensary districts—the dispensary doctor is the only doctor available within a reasonable distance. Consequently, in actual practice there cannot be a true choice of doctor in such areas. Indeed, one can go further and say that, were it not for the inducement of the regular salary attaching to the post of dispensary medical officer, there would be little to attract private practitioners to set up practice in remote districts with small scattered populations. It will be appreciated, therefore, that if it were not for the present system, there probably would not be the services of even one general practitioner available for the lower income group in these districts and, incidentally, for persons in other income groups who can afford to pay.

This objection does not, of course, apply to urban areas nor to all rural areas and we could consider a selective panel scheme for suitable districts. On the face of it, this seems feasible but I doubt if it would secure universal acceptance. The provision of a panel scheme in any area would be considerably more expensive than the present arrangement. In the typical county which includes both urban and rural areas, and in the areas of the Dublin, Cork, Limerick and Waterford health authorities, this would mean that the local authority would be asked to provide, and finance to the extent of one-half, a more expensive service for the town dwellers than for the remainder of their ratepayers. Now, it is true that urban authorities already provide services and amenities—water supply, sanitation, lighting and so on—which it cannot or at least does not provide for most of the rural dwellers, and this often gives rise to bitter complaints from the rural ratepayers. It is only rational to anticipate that county health authorities will be reluctant to concede a further expensive service to the urban areas, and to do this largely at the expense of the rural dweller.

Even if we could surmount this hurdle and bring in the panel scheme in selected areas, I can foresee at least one other big disadvantage in its operation. As Deputies will be aware, eligibility for the General Medical Service is governed by inclusion in the General Medical Services Register. The local authority decides the cases which are deserving of inclusion in the register and the standards which they apply are not infrequently a vexed local issue, some echoes of which we hear occasionally in this House. In saying this, I do not wish to infer that I believe that there is any general cause for complaint, but if any Deputy does believe that there are grounds for complaint, let him consider what the effect of introducing a panel scheme would be.

At present, it does not cost the local authority very much to add another name to the Register. The dispensary doctor's salary must be paid in any event and, apart from maternity cash grants, the only extra liability in respect of an additional individual would arise from the supply of drugs and medicines. This easy position would not obtain under a panel scheme. Every name added to the Register would mean that the local authority would pay to a doctor on the panel aper capita payment for that person (and, if he had dependants, for each of them) and would also have to budget for the medicines which might be prescribed for them by that doctor. A definite and immediate liability to expend a sum of, perhaps, £10, might be incurred by the inclusion of an additional name in the Register. This being the position it is likely that there would be much greater reluctance to allow an individual's name to go on a panel than there is now to grant him a medical card.

It will be clear from this that such a change cannot be readily made. It is, of course, a possible improvement which must fall for consideration in the future development of the health services; therefore I have arranged for my Department to assemble all the relevant facts and estimates of costs, and in due course the Minister for Health will be in a position to study the matter again in the light of experience.

It may be that some Minister for Health will be able to devise a scheme which will give a choice of doctor to everybody who is entitled to have general practitioner services free of cost to himself and his family. In all realism we must recognise that this is not likely to be feasible in this country, having regard to the pattern of distribution of the population. I think, however, it is essential that it should be accepted that it would be inequitable to provide such a service for urban dwellers only while requiring the rural ratepayers to contribute in proportion to their valuations to the actual cost. It seems to me, therefore, that if the right to choose their own doctor is to be afforded to these members of the lower income group who are resident in our cities and towns, the urban ratepayers must be asked to foot the bill. Indeed, there is a strong case in equity for permitting each urban area itself to decide whether it will allow those of its citizens who are within the lower income group to have a general practitioner of their own choice.

As Deputies are aware, it is my policy, as it was my predecessor's, because of the limited amount of funds and dental personnel available, to urge local authorities to concentrate mainly on providing dental treatment for those who will benefit most from such treatment, namely children. This means, of course, that only a limited dental service can be made available for eligible adults, those in the lower income group. Such improvements in the situation as we can achieve by the recruitment of wholetime dental officers in areas where they are urgently needed, and, in a number of the larger areas, by the appointment of senior dental surgeons who will organise and co-ordinate the services as well as carry out dental treatment themselves will still be inadequate for the provision of a comprehensive service for all those eligible.

There has been a certain amount of public disquiet from time to time here as in other countries, as to the possibility of "fall-out" from tests of nuclear weapons giving rise to a dangerous level of radioactivity in our food. I have answered various Parliamentary Questions in connection with it. During the past twelve months this matter has been the subject of a special study by officers from all the interested Departments. The results of the study, and of the tests which were undertaken in the course of it, will shortly be published. I can say, however, at this stage that the conclusions are reassuring and indicate, as we had anticipated by extrapolation of the results of similar tests in Britain, that no danger exists from radioactive fall-out in this country.

In speaking of last year's Estimates I referred to the Health Authorities Act, 1960. Since that time the transition to the new health authorities for the Dublin, Cork, Limerick and Waterford areas has been effected smoothly and with the minimum of disruption. The division of the expenses of the new Health Authorities as between the bodies which appoint them is an important feature of the Act and in this connection it is gratifying to record that agreement has been reached in the Dublin and Waterford areas in regard to the basis of contribution. Temporary arrangements, as provided for in the Act, are in operation in the Cork and Limerick areas and discussions in regard to the permanent basis for dividing the costs in these areas are in progress.

Many of the more important provisions of the Mental Treatment Act, 1961, were brought into operation on 1st April last. These included those relating to superannuation. The remainder of the Act will be brought into operation very soon. The relevant Regulations have been drafted and the necessary consultations are almost at an end. When the Bill was before the House I announced that I hoped to translate the complex superannuation provisions into more simple language and to issue this paraphrase as a memorandum to the staffs of district mental hospitals so that they could appreciate the effect of the options provided for. I am afraid that when the memorandum is issued in the near future it will be found not to be as easily understood as had been originally hoped but I know that interested Deputies and staff organisations will understand the difficulties involved.

Arising out of the decision of the Supreme Court in regard to the Solicitors Bill, 1954, it has been found necessary to consider the provisions in the various Acts relating to the registration of medical practitioners, dentists, nurses, pharmacists and opticians, dealing with disciplinary control in cases of serious misdemeanours which would lead to the persons concerned being struck off the appropriate register.

When we speak of broad developments under various aspects of health legislation or mention improvements which have taken place in the health services, it is sometimes easy to overlook the fact that these developments and improvements could not have been achieved without the aid of the necessary professional, technical and ancillary personnel. It is important that, in order to secure and retain staff of the required calibre and to ensure that the services will be of the highest quality, the remuneration offered to them does not lag behind that in comparable employments elsewhere.

During the past year I was glad to be in a position to accord unqualified approval to the implementation by health authorities of increased salaries for certain grades of medical and dental personnel. The increases were the outcome of negotiations between representatives of the various staffs concerned and their health authorities. I hope that the improvements granted will have the effect of attracting into the local services an adequate supply of suitable personnel and that they will help to overcome the difficulties which have been experienced in the recruitment of certain grades, especially junior medical staffs and dental surgeons.

In the case of nursing staff, proposals for increased remuneration are at present under consideration locally, following the submission of claims affecting all grades of nursing personnel employed in the local service. When proposals are received in my Department, I shall be glad to consider them as sympathetically as circumstances will permit.

It has been contended that the 1953 Health Act has been responsible for an unwarranted increase in the cost of our health services. I have already shown

(1) that much the greater part of any increase which has occurred has been due to the fall in the purchasing power of money and that this influence has been world-wide in its operation and

(2) that a substantial fraction of the increase has been occasioned by our efforts to make good certain acknowledged but deplorable deficiencies in our existing services, as, for example, the provision made for the treatment of mental illness and for the care of persons labouring under mental handicap in various forms.

Our efforts to deal with these and other problems, like the problem of rehabilitation, have resulted in increased charges on the community. But these have been largely offset by economies in the longer-established services, so that the net effect, as I have shown, has been to stabilise and, indeed, to slightly reduce, the over-all cost of the services in its relation to the gross national product.

We must all recognise, however, that, in its attitude towards the maintenance of the health of its individual members, the community must conform to the spirit of the times. It cannot be indifferent to the sufferings of even its least worthy citizen. Indeed, in charity, it is bound to succour him and, if he should be ill, to do its utmost to ensure that all therapeutic facilities available to it will be afforded to him. Equally such facilities must be available to all others who may require to have recourse to them.

With the increased development of medical knowledge and skill, the scope of all such services must expand. Unfortunately, it would appear that a concomitant increase in the cost of them cannot be avoided. So the natural trend is for the cost of health services everywhere to increase. I submit that I have demonstrated that in our case the increase, if any, has been nominal, though the improvement in our services has been striking. Taking everything into account, the amount which Dáil Éireann is now being asked to vote for the maintenance and improvement of the health services is reasonable, and I recommend the motion accordingly.

I move:

That the Estimate be referred back for reconsideration.

Before I deal with the matters which have been referred to by the Minister and with the point of view we desire to express, I think I should say that this is the fifth Estimate speech which the Minister has made as Minister for Health. Personally, I am glad to see that he has not lost any of the strength, virility and mode of expression which he has demonstrated so well in this House over the years. If in what I have to say on this important Estimate I appear to be critical of the Minister, I hope it will be understood it is not criticism of the Minister personally, because the Minister is a person for whom I have always entertained a very high regard. Having said that—having "cleared the decks," if you like—may dealing with the Estimate, inevitably deal with the Minister as Minister for Health.

In his speech here today the Minister has displayed—I assume intentionally —a certain feeling of complacency with regard to our health services, our present situation and what has taken place over the last few years under his administration. I wonder is that justified? First, I would ask the House to examine the record and to have regard in this debate to the fact that the Minister is now rendering an account to the House of his stewardship over the past five years. Inevitably, in discussing this Estimate, we must have regard not merely to the events of the last 365 days but also to the events of recent years, if we are to come to a proper decision as to whether the Department of Health has been properly administered or not.

We all know—many of us bear the battle scars of it—that, over the years, the subject of health has been a source of considerable controversy, controversy along a variety of lines, conducted and carried on by different persons— a controversy which at times had good aims and objects, but one which, at times, was bitter, spiteful and harmful, and, from a national point of view, dangerous. Indeed, the Health Act of 1953, under which the Minister administers many of the services he has referred to in his speech, was passed through this House at a time when this controversy of dissension and bitterness was, perhaps, at its height. Indeed, I can recollect, as most Deputies can recollect, that in 1953, when the Health Act was passed through this House, there was a state of almost open warfare between the then Minister for Health and the medical profession and persons in allied professions. That situation was deplorable. It would not be proper for or open to me to go into the reasons for it, but I do not think the reasons matter.

At the time the Health Act was introduced the situation was on all grounds most unsatisfactory. I recall to the House that, when the Government changed in 1954, it became my duty and my aim to end that unsatisfactory situation. I think I can say with some justification that I succeeded. By 1957 dissension and bitterness had entirely disappeared and when the present Minister became Minister for Health in 1957 he entered upon his high office with considerable advantages. The heat was off Health. I shall not say that the flags had been struck, but the drums had certainly ceased to roll. It is fair to say that many medical men had seen for the first time the inside of the Custom House, had learned to meet the officials of the Department of Health, and had realised that these officials did not wear horns and tails and cloven feet. That was a very healthy situation then and it was a potentially healthy situation when the Minister assumed office. I mention that because I think it is a matter that should be mentioned now.

In 1957 the stage was set for a period of orderly progress and advance in health matters. Perhaps to some extent I was at fault, but I have no doubt that in 1957, no matter what way one looked at the health services, there was tremendous room for expansion and improvement and the country was entitled to expect from the Minister for Health that whatever snags, problems and difficulties remained to be tackled would be tackled, resolved and overcome. They were entitled to expect from the Minister a continued attention to the improvement of health services and the implementation of the Act of 1953. I shall have something to say about that later. They were certainly entitled to expect that the last four-and-a-half years would have been devoted towards improving the health services available to them. There continues to be a whole variety of problems which require tackling. The recruiting of staff and the management of local authority hospitals is one example. I shall refer to that again. The provision of a dental service, of an ophthalmic service and of an aural service had not been solved in 1957. One would have expected that they would all have received attention in the last four-and-a-half years.

With regard to the problem of rehabilitation, again one would have expected in the last four-and-a-half years that the provisions of Section 50 of the Health Act would have been put into operation. In a variety of directions it was resonable to expect that some progress would have been made in the last four-and-a-half years. When the present Minister assumed office he had available to him a huge fund of goodwill and all he had to do was to avail of that goodwill in the interests of the services for which he is responsible.

We all know that unfortunately that was not to be the evolution of events. Beginning in a small way—whether it was intended, or accidental, I am not concerned which—a new break began to appear between the Minister and the medical profession. I am not concerned with who began it. It is very little consolation to persons around whom war is waging that some particular person or one particular side fired the first shot. I am concerned with the effect that the renewal of strife between the Minister and the medical profession has had—not on doctors; I am not concerned with them and I do not speak for them; not on the Minister; I am not politically concerned in any way with the Minister, and I certainly do not speak for him— on the health services and on the people of the country. We have had in the last four years, blowing sometimes hotter, sometimes colder, but consistently, a continued exchange of bulletins, incivilities of one kind or another, between the Minister for Health and the medical profession. We have had letters in the Press, replies, statements carrying particular meanings, half threats, and all the rest of it.

Indeed, quite recently, the Minister has apparently decided not to use his own name and he has got somebody else to write these letters for him. The voice is the voice of Jacob but the hand is the hand of Esau and I have little doubt, so long as the Minister continues to display the attitude that he must score off the medical profession, or the Medical Association, no basis for an understanding can be established. As I say, I am not concerned with the rights or wrongs of it, but I am concerned with the effect of it; and the effect has been—the Minister must realise this—that there has grown up a sense of frustration, of bitterness and a profound lack of trust in so far as the medical profession is concerned. So far as the Department of Health is concerned, the Department has been deprived of the advice and the assistance it should have had in the last four-and-a-half years.

I know that this is a political question. The Minister has been in politics long enough to know these things better than I do but I would expect that a hard-headed politician may feel that politically it is a sound thing to war with the medical profession. Politically, there may be votes in continuing a senseless strife with Irish doctors but I do not think that that is in itself a justification or, indeed, an attitude that should be adopted by any Minister for Health.

Last year, I referred to this matter and I appealed, in so far as an individual Deputy could, for some birth of understanding on the part of both the Medical Association and the Minister. The point of view I expressed was repeated by other Deputies. The fact is that there has been no change and no effort on the part of the Minister or, so far as I know, of anybody else, to bring this senseless rowing to an end. It has continued just the same, unabated, and the people have had to bear the consequences. It is now too late, I suppose, for the Minister to do anything about it. The Minister has introduced his last Estimate and accordingly we can only look in another direction for restoration of some measure of peace and harmony between the medical profession and the Minister for Health.

I do not understand what the dispute is about but certainly there is no question of principle, policy or philosophy involved because those differences were overcome a number of years ago. What is involved now is, perhaps, just a disharmony in personalities more than anything else. The effect of all this is felt by the people.

Having said that, I want to refer to what I regard as the problems which face the Minister and which should have been engaging his attention. In this debate today, the Minister has defended the Health Act and the policy enshrined therein, in accordance with his duties as Minister for Health, but there are grave criticisms to be levelled at the manner in which the services under the Health Act are at the moment provided. I propose to mention some of these difficulties as they appear to me in order to illustrate the vast amount of work which still remains to be done before this country has available to it a proper health service.

In the first place, I should like to refer to the general medical service. I suppose that service is best understood by mentioning the words "medical cards". The general medical service was put into the Health Act introduced in 1953 to replace the red ticket system of medicine. Indeed, I remember speeches made by the Minister's predecessor and other members of the Minister's Party at that time. One could only feel that something wonderful was to be achieved if the red ticket were to cease and this medical card were to take its place. The reality behind the general medical service for the poor is that nothing new was intended and that the same service as previously existed was carried over in the Health Act, 1953. That, of course, is the dispensary system of medicine that was first introduced here under the Poor Relief (Ireland) Act, 1851.

I shall not spend any time in criticising the dispensary system, but I do say that it was never intended to be anything more, and has not been anything more, than an emergency service for sick or dying poor people. It was so introduced. That was the object of it 100 years ago when starvation and famine stalked this land. It was intended to provide an emergency medical service against the mishap of starving poor Irish people dying. That is the philosophy behind the service. That is what it was designed to achieve. Unchanged, it is in the Health Act, 1953.

I wonder was that understood? In 1953 or 1954, when people were asked to vote for the Fianna Fáil Health Act, was it understood that the very medical service which they were promised was merely the mixture as before, the British dispensary charitable medical service which had been in existence under the Public Assistance Act of 1839 and other statutes? In any event, there it is, in the Health Act, under Section 14, and it is provided in accordance with regulations which have to be made and which have been made by the Minister for Health and it is available to persons defined as persons who are unable by their own industry or other lawful means to provide for themselves. That is the definition of a pauper and this is a pauper service, intended for that purpose and, in fact, in accordance with that section, so operated.

I should like to question—I was certainly concerned about it when I had the responsibility—whether that kind of free medical service is good enough for this country. Is there any reason for the complacency the Minister displayed with regard to it here this evening? Is it good enough that in 1961 this country would have precisely the same medical service as it had in 1851? Are we to shrug off the fact that 110 years have passed and that certainly in relation to the duty of a State towards its citizens there has been a growth and a profound change in social outlook and in what is regarded as being the duty and the obligation of a State. There it is. That is the general medical service that we provide today for this country and the Minister for Health is complacent about it and, apparently, thinks it is satisfactory.

That service, bad as it is, poor as it is, is administered in a particular way under dispensary medical officers appointed by health authorities on the recommendation of the Local Appointments Commission to provide the service in particular areas. Could anything be worse? Granted that the dispensary system is a poor quality service—as it is administered by a single doctor who is paid a salary for doing it, obviously the type of service is going to be very bad indeed. There is no incentive to provide a better or improving service, no incentive on the part of the doctors. They do their best, I know, within the limitations of the dispensary service.

The Irish dispensary doctor has done a tremendous amount but there is little incentive for better medical practice. Many dispensary doctors in the more populated areas also find they have so many calls upon them that they cannot deal adequately and properly with sick people in their homes. Remember the service as it is operated in accordance with the regulations is a service for the sick poor at a stated dispensary at a stated time. They must be in the place designated at the appointed time but if a poor person is sick and in his home, the doctor must call upon him. That takes time. It involves the difficulty of doing it and, of course, frequently that sick person is sent to hospital because the doctor has not time available adequately to treat him as a domiciliary patient.

The result of this cheap, poor, medical service has been, in many cases, a very high hospitalisation rate. I often wonder, as I have mentioned before, whether, in saving halfpence and pennies on general medical services, we have not been adding quite enormously to the health services bill in relation to hospitals. I have little doubt that the high hospitalisation rate in this country and, particularly in the most populous areas, is due to the fact that under the present dispensary medical service, it is found the easier thing to do to send the person concerned to hospital. That is one defect, and a serious one that should command attention.

There are other defects which must be faced. The free medical service under the Health Act is available, of course, only to a limited section of the population. Those who qualify within the definition are the very poor who cannot provide for themselves. No medical service is available for anybody else. I wonder was that appreciated and understood when the Fianna Fáil health scheme was put before the people in the 1954 general election. Was it understood that under this Act the worker, the small farmer, or the ordinary self-employed person who becomes sick or whose child becomes sick has no claim whatever to avail of the medical service in this country? He has to go out in the middle of family illness, pay the doctor, go to the chemist, and pay for drugs and medicines and face all the increasing expenditure on these matters. Under the services as they are, that person—and there are hundreds of thousands of them—is not entitled to any benefit.

Apart from the limited scope of the general medical service, it is also true —I think this may be accepted now but it certainly is strange—that those who provide the money for the service, those who have to bear the cost of it, the ratepayers, no matter what their rates may be, must finance the health authority's contribution towards the cost of the general medical service and they are still deprived of any benefit from it for themselves. That is a strange position. It is strange that the cost of this service should fall upon many people who are automatically deprived of any benefit from it.

I mention this question of the general medical service as one problem inherent in the administration of the Health Act that should have got attention over the past 4½ years. When I was Minister for Health, I expressed the hope that something might be done in an administrative way to improve the dispensary system of medicine and I suggested providing at least a choice of doctor. I think I mentioned that last year on the Estimate and the Minister —I am personally obliged to him—has obviously given the matter some considerable attention in the past 10 months. I wonder what decision he has come to because in his speech here today he was—if I may say it without being offensive—blowing rather hot and cold. He said it would be a good thing to provide a choice of doctor but there were difficulties of one kind or another.

I agree that there are difficulties and I think anybody who studies this problem would not be surprised to hear that difficulties did exist, but the difficulties that are there now in 1961 are all difficulties which I certainly anticipated back in 1957. If it is the concern and obligation of the Minister for Health to provide within the framework of legislation passed in this House the best possible service, why, in the past 4½ years, were these problems and difficulties not tackled?

Section 14 of the Health Act lays down that a general medical service is to be provided by health authorities in accordance with regulations made by the Minister. That does not mean any kind of a health service. It means that a Minister charged with that responsibility must ensure, within the limits of his powers and the legislation passed, that the best possible service is provided. He may have difficulty with his colleagues. That is one obstacle he must overcome, but I have little doubt that if it had engaged his attention over the past 4½ years progress could have been made. The fact unfortunately has been that the Minister, so far as the record is concerned, gave this matter no attention, with the result that he can come in here with his fifth Estimate speech and refer for the first time to a choice of doctor in relation to the dispensary service and say: "Well, I am having the problem assessed so that somebody else, if he wishes, can deal with it." That was a very poor report for the Minister to give to the House. In relation to health, we have given the Minister every possible opportunity to make progress. We have not tried to make health a political issue as it used to be and if we are critical this year on the subject of health, we have good grounds for being critical.

I want to refer now to the dental service. I do not know whether you realise, Sir, that away back in 1953 this House in passing the Health Act of that year passed the section which provides that "a health authority shall"—not "may"—"in accordance with regulations, make available, either, as may be specified in the regulations, without charge or at charges approved of or directed by the Minister" a dental service and dental appliances for all persons insured under the Social Welfare Act, 1952 and for their dependants, for all adult persons whose yearly means were less than £600—it is now £1,000—for all farmers with a valuation up to £50 and everybody else who could establish any case of hardship. All these people, their wives and families and all poor people were, under Section 21 of the Health Act, 1953, to have a complete dental service and, in addition, were to be supplied with all the dental appliances, dentures, and so on, they might require.

That is a section of an Act of Parliament passed eight years ago, part of the Fianna Fáil health scheme, part of the case they made to the people in the general election campaign of 1954 when they had posters up referring to health and wealth: "Vote for Fianna Fáil: Look at our health scheme— a free medical service." A dental service was to be provided for 85 per cent. of the population, for all poor people, all insured persons, all self-employed people up to £600 income, all farmers up to £50 valuation, and then for good measure, for anybody else who had a hard luck story to tell.

I should like to know what report the Minister can give us now in 1961 as to when this service will be provided. It is worth recalling that my immediate predecessor in office as Minister for Health who steered this Bill through the Dáil was obviously sublimely confident or perhaps he was affected by other views, when he made these regulations and decided to bring this scheme into operation. When I became Minister for Health, I was appalled when I came to look at this problem of the dental service away back in 1954. Apart altogether from the money—I did not know where the money was to come from—neither the dentists nor the facilities were available. I decided at that time as a limited decision—although I was committed by an undertaking given by me on behalf of my colleagues as fully as possible to implement this Act—that this section dealing with the dental service could not then be operated and with the authority of the then Government, I decided not to proceed with it at that time and to concentrate on building up the school dental service.

The Minister has referred in his speech today to that decision which was taken seven years ago to build up the school dental service and to continue whatever service was possible for poor people. Is that all the Minister has to say? That is the decision I announced in 1954 and indeed I was ballyragged in this House by the Minister's colleagues as to why I had scrapped the grand Fianna Fáil dental scheme contained in Section 21. I explained to them then and I hope I have convinced them that it was not possible then to implement it.

What progress has been made since? What, if any, progress has been made over the past 4½ years in providing this dental service for which this House was asked to legislate by the Fianna Fáil Party? Is legislation passed by this House just to be treated as if it had never been passed? I am speaking as one who opposed this section and opposed this Bill and I am speaking across the House to a Minister who supported it and voted for it. Is this just to be thrown away as if this section had never appeared on our statute book—a dental service for 85 per cent. of our people? I did not believe it was possible at the time and I think it has been proved that it was not possible and was not intended. However, what I am concerned about is, what in fact has been achieved? I decided to concentrate on a school dental service and the Minister has continued it. I assume the Minister will be able to tell us what progress has been made in that regard.

What about poor people? Let us forget about all the 7,000 insured workers that were supposed to get a dental service. Let us forget about the self-employed person and the farmer up to £50 valuation and the hard-luck cases. All these people were led to believe they were to get dentures and the services of dentists on the rates. Surely in the last four and a half years the Minister should be able to tell us that at least some progress has been made in providing a dental service for poor people?

Of course, we know the Minister cannot tell us that. Today in this country, just as in 1954, there are poor people who have been applicants for dentures. They hold medical cards. They are persons unable to provide for themselves, who have been seven, eight or nine years waiting for the provision of dentures, people who, nine or ten years ago, had all their teeth removed. In accordance with that section, they applied to the local health authority for the provision of dentures. Of course, they cannot get them because the service is not there. The scheme has not been devised. No progress has been made in providing the service and they are without any relief.

Again, if the Minister, instead of spending his time carrying on an abortive row with the I.M.A., had been, as he should have been, concerned with the poor people who were supposed to benefit under this section, we would expect him to be able to say: "Well, I cannot yet bring in Section 21 in full, but at least I am now in a position to provide a dental service for poor people." Instead he says in his speech here today what I had to say—and I was ashamed to have to say it—to every health authority in the country seven years ago. I had to say it but I certainly would have felt that seven years later somebody else would have been in a position to report something a bit brighter.

There it is. There is a dental service under this Health Act of 1953 and it might as well never have been put into the Act. I do not know why the House was asked to pass that section, a section which puts a statutory obligation on health authorities to provide this service—a service that apparently never was really intended to be provided and certainly a service in regard to which the Minister has not been able to show any progress.

That is the dental service under the Health Act, but there is also an ophthalmic service. Again, an ophthalmic service was one of the carrots put before the people in the general election of 1954. They were told that, under the Fianna Fáil Health Act of 1953, there would be available not only for poor people but for every insured person, his wife, his children, and his dependants, for every self-employed person running a small shop or whatever it may be, for his or her dependants, for every farmer—not the small farmer only but every farmer up to £50 valuation—an ophthalmic service with the services of specialist and experienced people. They were told that if they or any of their dependants required them, they would get glasses and ophthalmic appliances under this service.

That is in Section 21 of the Health Act. Again, this service was not to be a discretionary matter; it was to become a statutory obligation on the health authority. I do not know what has happened about this service. It certainly is not there. The Minister cannot tell us anything about it. Apart from the glasses provided under the Schools Medical Service, as far as I know there are no ophthalmic appliances or glasses provided at the moment even for poor people. This scheme is not operating. Again, one would expect the Minister to be able to report some progress in this respect.

There are two services, a dental service and an ophthalmic service. I have little doubt that many a Fianna Fáil Deputy or candidate made grand speeches some seven or eight years ago about the benefits that were to be provided in this kind of service. But there is a third one, an aural service. Under Section 21 of the Health Act, 1953— again with no question of discretion— every health authority is placed under a statutory obligation to provide hearing aids for persons who require them —all insured persons and their dependants; all farmers up to £50 valuation; all self-employed persons up to £600 a year and so on. Everybody must have known when this was urged here that any service of that kind would have been a difficult, and, probably, an expensive one. But the then Fianna Fáil Minister for Health would have nothing to do with that. It could be provided; it was going to be provided; it was put into the Act. But where is it today? I would suggest that one could count on one's ten fingers the number of hearing aids that have been made available, even to poor people, in the last eight years. The service just is not there and there is no evidence that it is going to be there.

Again, leaving aside insured persons, farmers and so on who could be expected at least to contribute to the cost of these things, poor people who have no other means apparently can go to their grave without them. If they need a hearing aid, they certainly will not get it. The only trouble is they will not be able to hear the apologies made to them for not providing the service they were promised.

There are three services under this Act about which we do not know anything. But the story does not end there. The Health Act of 1953 also provided, in Section 50, that a health authority shall—again there is no question of discretion—make available a service for the training of disabled persons for employment suitable to their condition of health and for the making of arrangements with employers for placing disabled persons in suitable employment. Again, this rehabilitation and maintenance service for disabled persons was part and parcel of the Health Act this House passed eight years ago, and again we are entitled to know what progress has been made in that regard.

The Minister made a slender reference to rehabilitation. He referred to the National Organisation of Rehabilitation which I established. I established that Organisation as an advisory body to examine the problem of rehabilitation and to advice the Minister for Health on the way in which the necessary services could best be provided. That Organisation was set up in, I think, the year 1955. I do not know when it reported, but I should have expected that the Minister today would have been able to give us some indication or evidence of this service going into operation. Instead, he referred to the fact—I was glad to hear it—that the Lourdes Hospital in Dún Laoghaire has been taken over. The decision in that respect was taken twelve months ago.

I do not regard the taking over of a hospital for this particular purpose as anything more than a mere beginning in the provision of this service. When I was concerned with the problem there was considerable agitation on the question as to whether one of the two existing fever hospitals in this city should be made available for rehabilitation. That was six or seven years ago. I appreciate that probably the wisest thing would be to have a national rehabilitation centre but that, in addition, there ought to grow up in each health authority area some system for referring disabled persons to a particular centre and providing, under Section 50 of the Act, for their training and their subsequent employment in the particular health authority area. I cannot understand how any responsible Minister charged under Act of Parliament with a particular duty can allow these provisions just to lie there, as if they had never been passed. A rehabilitation and training centre is urgently needed. Those provisions were one of the finest features of the Health Act of 1953. I think it is a great pity that today, eight years later, this urgent problem should be shrugged off as something that is apparently unworthy of Ministerial attention.

I am glad the centre is now available. I am glad it will be in a hospital run by an Order with a fine nursing tradition. But considerably more will be expected. At the moment a voluntary body is concerned with the problem of rehabilitation and in seeking public understanding for and appreciation of the problem of disabled persons in this particular year. This is the year they have dubbed "Rehabilitation Year". The Organisation has visited different counties, talking about rehabilitation. It is talking about a problem that many people do not know exists.

Had Section 50 of the Health Act of 1953 been put into operation and administered, as it should have been, there would now be available at least an understanding of the problem and at least some limited arrangements would have been in operation to provide for the placing of disabled persons in employment. They are not there and any work that is being done in that respect is being done by a body of enthusiastic people who are doing their best with limited means. The Minister said that the object of the National Rehabilitation Organisation was to co-ordinate the activities of different bodies. I agree that was the primary object and I would have hoped that. with the support and understanding of the Minister, that Organisation would now be in a position to make Section 50 of the Health Act something real and vital instead of just, as it is, so many black letters imprinted on a statute book, overlooked and forgotten.

I am afraid that the real position is that the Health Act of 1953 was intended as an election gimmick. It was not really thought out except for the limited purpose of getting for those who proposed and supported it some political advantage. Although that Act was opposed by the Fine Gael Party, I, as a member of that Party, and as a member of the last Government, had the responsibility of being the first to try to implement it. I think I can conscientiously say that I brought to the effort of implementing it as much enthusiasm as if the Act represented my own political view and outlook. I have little doubt that, when I charge the Minister with his failure to provide the services that should have been provided, the services have not been provided because it was found impracticable to provide them. The deduction is, therefore, that the policy enshrined in the Health Act of 1953 has proved after a fair trial to have been erroneous.

An attempt to build on to a pauper system of medicine a health service for a modern State could never succeed. The cost of the attempt, as the Minister has had to admit, is out of all proportion to the benefits conferred. In many cases that cost has had to be borne by those who will never benefit. In only one respect in the last eight years has any real progress been made in health matters. I refer to the Voluntary Health Insurance Scheme. That scheme, which came into operation in 1957, has been a considerable success. It is the one bright spot in our health services in recent years. Maybe it is a beacon. Maybe it is an indication that it is along the lines of real community effort that real progress should in the future be expected.

I want to pass now from the administration of the Health Act to one or two other matters. The Minister has referred to the building of new hospitals. He has referred to the liquidity of the Hospitals' Trust Fund. He says that because of this apparently newfound liquidity it is now possible to proceed with the building of Erinville Maternity Hospital, Cork, the new Coombe Maternity Hospital and St. Vincent's Hospital, Dublin. I should like to say again, for the record, that if there had not been a change of Government in 1957 these three hospitals would now be receiving patients. They were part of the building programme that I had approved of and given directions for completion in 1956. I decided that these and other hospitals would be built in accordance with that scheme in the belief and on the assumption that the income of the Hospitals' Trust Fund would continue to be not less than £2,000,000 per year. I should like the Minister to say, when he is concluding the debate, whether I was wrong in that respect or not. In fact, the Hospitals' Trust Fund income has been very much more. If the building programme that I had approved of had not been interfered with, the St. Vincent's Hospital and the other two hospitals that the Minister mentioned would now be completed and also a variety of smaller projects throughout the country.

The Minister decided that that was the wrong approach and that he would not permit the building of any of these hospitals until there was banked up in the Hospitals' Trust Fund a sufficient sum to pay for the building of these hospitals, assuming that they could be put up just like that. I wonder was that wise? Four-and-a-half years have been lost. I have little doubt that costs have gone up in the interval and that they could have been built at a cheaper cost four-and-a-half years ago. In the interval the money that has been accumulating in the Hospitals' Trust Fund has been invested, has been lent by the trustees to the State, put into our National Loans. I wonder has that been a good thing or would it have been wiser, as the money came in, to spend it on designated projects over a definite period so that all the time the money would be used for useful purposes. I assert that these three hospitals would now be completed if the decision which I took had been observed.

There is one other matter. The Minister said at the conclusion of his speech, in relation to the subject of staffing, that a recognition of a fair reward and higher remuneration for medical staffs would be beneficial—I agree— and that it should lead to the overcoming of difficulties in the treatment of certain grades, particularly junior medical staffs and dental surgeons. I wonder what is the position with regard to junior surgical staffs in the local authority hospitals? Certainly, if my information is correct, many of our county surgeons, highly qualified and first-rate men, find it extremely difficult to carry on without some reliable surgical assistance available to them. I believe that this is largely a matter of money and organisation. I should like to feel that some progress is being made in that regard.

I know the Minister could not refer to everything, but he did not refer to what the present position is in relation to nursing services. Perhaps when the Minister is concluding the debate he will be able to tell us what progress has been made in the last 4½ years in the provision of a district nursing service. It was, I think, the correct policy, decided on some years ago, to aim at having as the right-hand of the dispensary medical officer in small districts in every county a district nurse who would be able to help in domiciliary nursing and in a variety of other field work.

I should like to feel that that type of nursing service has grown in recent years and that there are more district nurses available now than there were initially. My feeling in relation to that kind of service was that it should be patterned on the idea of the Jubilee nurse and that that type of girl should be encouraged to come into the health authority service and to provide general nursing for persons in need. I hope the Minister may be able to tell us something about that.

The Minister did not deal in detail —of course he could not—with the present situation in relation to the school medical service. I should like to know generally how often a school medical inspection is carried out. Certainly, some years ago the interval between medical inspections was quite frighteningly long. I should like to feel that the interval is now not as great and that more frequent school medical inspections are carried out.

These are the matters I wanted to mention on this Estimate. I think, as I have said, not in relation to the Minister personally but in relation to the administration of the Minister in the last 4½ years, the progress which should have been made has not been made. Problems which should have been tackled have not been tackled. I feel that this has been due to Ministerial distraction by rows and strifes with the Medical Association and bodies of that kind, which have added up to nothing but frustration for the people. The people have had a continuance of a health service which, even at the best of times, would not be very good, but in which the snags and difficulties are very much greater now. It is not surprising that, as a result of all that, people are profoundly dissatisfied. In relation to all these matters the Minister must take responsibility and it is for these reasons that I have moved that the Estimate be referred back.

The Minister has given a most comprehensive review of the activities of his Department for the past 12 months. Yet, like Deputy O'Higgins, I think it may be well if we get back to fundamentals and deal first with the problems that we—particularly in our own areas—find are still weak links in the chain of health services. The first of these, I believe, is the problem of our dispensaries. In very many instances, particularly in South Cork, these dispensaries are deplorable. The Minister is, to a large extent, responsible for that. I do not say he is solely responsible because, long before he became Minister for Health, the local authorities could perhaps have concentrated more on providing financial help for the replacement of these disgraceful buildings but in 1957 under the Health Act a little work was going on to replace these old buildings. Then, the present Minister for Health said that, bad as the situation was, he would see to it that the grants for the erection of these buildings would be completely removed. That was a big loss to the local authorities.

By the action of the Minister local authorities found themselves in the most unenviable position of having to provide more money for the erection of dispensaries at a time when all opinion, even among the members of his own Party, was in favour of more co-operation and financial help for local authorities. The Minister decided in 1957 to cut out the grants then being made available to local authorities. Even at this late stage, I ask the Minister to have this matter re-investigated and see if he is not able to advance a little more money so as to provide more financial help to local authorities for the very necessary dispensaries.

The Minister spoke of new hospitals. New hospitals have been erected in the past few years, and in the years prior to that, but we know there is need for much more work in that respect. The Minister undoubtedly is fortunate because according to what we hear the amount of money being made available from the Hospitals' Trust Fund and becoming available for the erection of hospitals, is increasing. Much more should come to the hospitals as the gift it was intended originally to be. Unfortunately, some people are having too big a slice out of it. No wonder they have race horses. I suppose that is not the Minister's fault.

In Cork we are in the unfortunate position of wondering what the Minister will do. Shall we ever know the result of the regional hospital versus St. Finbarr's controversy? I shall not go into details because no doubt my colleague Deputy Barry will blossom forth about it in a way that may appeal more to the Minister than my contribution. Yet it is time this "joke" were ended. We have some money going astray before being devoted to the proper use for hospital purposes, more of it going astray in squandermania—not being spent by the Minister but spent in fees amounting to £50,000 that have been handed out in connection with the proposed new regional hospital in Cork, a hospital that probably will never be built. The money is gone and even if it is not all paid to the people concerned it will have to be paid. After all that we have only the land and no hope of a hospital.

The question arises: do we need that hospital? We want the Minister to decide that. I should like to anticipate the Minister saying that some members of the various local authorities in Cork are divided in their views on this but, strangely enough, it is one thing on which Deputy Corry and I agree. We believe there is no need for the regional hospital because in the past few years St. Finbarr's has been so improved that we now have specialist services there that we did not have eight or nine years ago when some of us believed the regional hospital was required.

In view of the services we now have in St. Finbarr's, we believe it would be far more beneficial if we could utilise the space available in the County Home part of the building for the improvement of St. Finbarr's, providing more accommodation where we have such good services. That would be a better proposition than to start building a regional hospital, which we know, would mean duplication of specialist services.

Being a regional hospital we would only have a quota of beds available there. We believe it is essential that the Minister should decide. We take it he will be in favour of Deputy Corry's view this time and not in favour of the regional hospital but the money that is available for the project is money that is due to Cork although not yet handed over and should be made available for St. Finbarr's and other local hospitals. The money is available, we believe, and it is needed.

Money is necessary for the improvements required in these old—I hate to use the word—workhouses in Kinsale and Youghal. We are anxious to have these improved for the sole purpose—which is fundamentally important, I believe, when approaching the question of improved services in St. Finbarr's—of transferring patients from St. Finbarr's to them. Even if the Minister's architectural advisers are against this proposal—the architect in Cork was against it—these professional gentlemen often want to build from the ground-up beautiful new buildings. We are trying to be practical and improve the existing ones some of which are solid stone structures. Even if we must replace the roofs or make improvements inside, nevertheless we have foundations and solid walls to build on. If we could do that and get the permission of the Minister and financial assistance for making a start on improving these old buildings in Kinsale and Youghal it would automatically mean a transference of 300 or 400 patients from the county home part of St. Finbarr's. That will give us the necessary space on which to build for the improvement of the general hospital at St. Finbarr's about which we are so concerned.

We want the Minister to decide this. I do not wish to be sarcastic but I suppose the life of this Parliament will not be prolonged by more than a few months. Whatever we do afterwards, let us, before we go, have a decision in favour of St. Finbarr's as against this regional hospital.

There is the old problem of the small hospital building in Cork. I cannot understand why the Minister is so adamant in refusing to let use be made of the fever hospital in Macroom. Members of the local authority last Friday went out and inspected that building. It would be a great benefit if permission were given to allow 25 to 30 patients to be transferred there. That building is lying idle and surely there must be an end to that. The Minister spoke of the dispensary doctors and of their duties in connection with medical cards. I agree with him that there are some good dispensary doctors and some very bad dispensary doctors. I suppose that applies also to Deputies.

And Ministers.

I do not know enough about them. As regards the dispensary doctors, some of them have the happy knack of advising an unfortunate person to go and see a specialist in a particular part of a certain city. The person is often sent to hospital as a private patient for which he is going to pay dearly. That does not happen in all cases, to be fair to the dispensary doctor, but we cannot stand for people being sent to a specialist who sends them to a hospital where they are given private accommodation which they cannot afford.

The Minister completely ignored the problem posed day after day not by the dispensary doctors but by our county managers. The Minister always seems to have a particular regard for these managers but it is about time he realised that very often the manager in the local authority is far more responsible for some of the problems which arise each day affecting the lives of the people who should be getting these benefits but who are not. Deputy O'Higgins spoke quite rightly of the position of the insured persons and of those who should automatically get benefits under the Health Act.

Deputy Corry and other members of the local authority will no doubt recall decisions made by the county manager, now the health authority manager, denying people the benefit that should have been theirs in respect of the provision of dentures. One aspect alone in which predominance was given to the view of the manager was in relation to the age of the applicant. If he were around 70 years of age and had his teeth removed, the manager might decide he was too old to benefit and that he must continue for the rest of his life without dentures. As Deputy O'Higgins said, the provision in the Health Act specifies not that we "may" but that we "shall" give these benefits. It is about time these managers were given a direction by the Minister; the members complain often enough. When the managers of the various counties come together and plot their campaign it is very hard for any local authority member, from whatever Party, to upset the pattern set by them.

As well as being denied this dental service, people are denied hearing aids to which they are also entitled. There are cases in County Cork of people who should have got this benefit and to whom it was denied. The manager will insist that the person must be almost stone deaf, secondly, that he or she must live somewhere around Patrick's Street where the traffic is as dense as it has been in Dublin for the past few nights and, thirdly, that he or she must be the father or mother of a young family so that, in the event of the death of the person, he or she would be a loss to that family. That nonsense should be ended. The people should be given what they are entitled to under the Act and the Minister should be able to tell the managers where to get off in this respect.

People are also entitled to spectacles under the Act but there is a long waiting list. People are kept waiting for twelve months, two years or longer for a pair of spectacles. No wonder people are dissatisfied with the situation. As a member of the Labour Party I would support the introduction of a Health Act that would be of benefit to these people. In spite of the intentions of the then Minister and of those who supported the Health Act when it was passing through the House, the people are being stymied and being denied their rights by these dictatorial managers.

Another extraordinary case has arisen in Cork. I do not know if it applies in other counties. If a person is receiving a blind welfare allowance at the age of 60, 68 or 69 and then gets an old age pension at the age of 70, the blind welfare allowance continues. However, if an old age pensioner becomes blind at the age of 70 or over after receiving the old age pension, he will get no welfare allowance from the manager. That is the most unchristian behaviour anyone could expect in connection with the health service. The Minister should have this matter investigated. What I am telling the Minister is not just hearsay. Members of his own Party from Cork city and county can bear me out. It is about time those who supported the introduction of the Health Act and those who, by their votes, decided that the Health Act would be put into operation ensured that it will not be left to a few dictators to decide what should be given and what should not be given under that important Act.

Of course, we have the problem of medical cards. I have to admit the position is even worse now than it was with the damn red ticket. The home assistance officer reports on the means of the applicant and it ends up with the manager. People we believe should get medical cards are denied them, but it is extraordinary to see some of the people who get them. The present manager in Cork showed the line he was taking. To qualify for a medical card, the family income should not be more than £6 per week. If it exceeds that figure, the manager says such an applicant may be deprived of a medical card. Taking into account the difference in money values, it means that a person who had a wage of about £3 per week prior to 1952 should not get a ticket for the dispensary, and that a person who had a wage of £2 5s. or £2 6s. prior to 1939 should not get a ticket for the dispensary, but we know that such people were entitled to that service at that time. But now if such people have a shilling or two over £6 a week, they are denied that service. In the case of a man with a wife and one child, £6 10s. is the maximum ; and if there are two children, the second child is worth only 5s. 0d. In my opinion, the manager should be far more liberal in his approach to this matter. If we have a Health Act at all, let it be a good one.

Deputy O'Higgins mentioned some schemes. It might be possible to have these in a few years, but I am concerned, not with the future, but with the present. When we are dealing with our estimates in the county council in February or March each year, the manager is quick to get money for this, that and the other thing, but he is just as quick to act contrary to the view of the members and refuse to give medical cards to people we believe to be entitled to them. The Minister should have a conference—not a conference for cutting down such as we have had in the past—to see that these people will get medical cards. He should tell the managers to realise that present money values should not be related to the value of money at a time when medical cards were given on a different basis.

The Minister drew attention to the establishment of the Commission on Mental Health. I am glad such an approach is being made, but there is one weakness in it. Examine the activities of each Government Department, find out the number of commissions established, the length of time they took to report and how little notice the Minister or the Government ever took of their reports. I am afraid that by the time we get the report of this new commission and it is acted upon, there will have to be a very big change in the country. If we are to judge by what has happened in the past, conditions in our mental hospitals and the treatment of our patients will be in the same deplorable state for a long number of years.

We have the present extraordinary position whereby the staffs in mental hospitals very often have to live in overcrowded conditions. They are very often in the position—I am speaking particularly of Cork—of being denied overtime or proper time off. They are not provided with the necessary facilities for people working in mental hospitals. They have very onerous jobs and they should get much better treatment, more opportunities for advancement in their profession and better wages and conditions than they have at present. I ask the Minister, while waiting for the report of the commission, to consult with the unions concerned and get the full facts of the conditions in which some of the staffs have to live in their off-duty hours. We should start by making these improvements and not wait for the report of the commission.

Deputy O'Higgins spoke about the schools medical service. I should like to inquire about the length of time elapsing between each examination. I know that up to a few years ago in Cork it was not uncommon for a medical officer to call to a school and not be seen there again for another three years. Of course, it was not his fault; it was due to shortage of staff. Though I believe the position is better now, it still could be considerably improved upon. In my opinion, the weakness is that, even if we had sufficient staff, the Act lays down that a child must be medically examined only three times during his school going period. That is not sufficient. I have known of some extraordinary cases myself. I know of a child who was examined by the medical officer in the local school and found to be all right, but in the period before the next examination the child became ill. The parents had not a medical card and could not obtain benefit. Because they could not prevent the child from getting sick before the next examination in the school, they lost all the benefits of the schools medical service as well. It is essential that there should be provision to protect the health of the child right through the school years, from six to 14, particularly in the case of parents who do not hold medical cards. I think it is important that such provision should be made.

I mentioned specialists. I want to refer now to their counterparts, the dispensary doctors. I have always been of the opinion that a better dispensary service would be the ideal. Away back in 1951 some of us pleaded with the then Minister for Health, and eventually secured from him the right to employ a general-trained nurse in dispensary areas. The nurse has proved invaluable and I believe that a general-trained nurse should be available in every dispensary. That would help to relieve the problem of overcrowding in the dispensaries attached to hospitals. Some dispensary doctors are better than any specialist. Many people will not go one foot beyond them because they realise they can depend on the local man. They know his abilities. If we avail of their services along properly co-ordinated lines we can, I believe, build up an excellent local service.

It is an odd commentary on the development of medical science that, as the years go on, there are more and more specialists and more and more medical problems for which specialists are needed. An even odder commentary is the fact that that evolution is not helping the community as a whole or improving the health of the people generally. I admit we need our specialists. Far be it from me to take from them in any way, but very often the local man is better than the best of them. If we co-ordinate the dispensary service, supply properly trained nurses, and improve facilities generally, we will, I believe, improve the health of the people.

Hospital charges were increased some few years ago from 6/- to 10/- per day. If we could keep the people out of the hospitals by giving them better services in their own areas we would be doing a good day's work. We might, indeed, be able to prove that the Health Act of 1953, with all its weaknesses, is some contribution towards improving the lot of people faced with illness and the heavy financial burdens illness can involve.

I heard Deputy O'Higgins tonight speak of Saint Vincent's Hospital and how he was prepared to allocate some £2,000,000 from the Hospitals Trust Fund to that hospital in 1956, and I began to wonder. I should like to see the records of the Cabinet meeting of the inter-Party Government in 1956 at which it was announced that there was £2,000,000 anywhere, and to see the fighting there was for it. Two million pounds rings a kind of bell in my ears. We are back in 1949. As Chairman of the South Cork Board of Public Assistance I received an urgent message from the Minister for Health, Deputy Dr. Browne, to proceed immediately, with my Vice-Chairman and the county manager, to meet him in his office in the Custom House to deal with a matter of the utmost urgency, namely, the building of a new regional hospital in Cork. I remember coming up here with the late Pa McGrath, God rest his soul, the Lord Mayor of Cork and my Vice-Chairman, and the county manager at the time. We met the Minister and his advisers.

We were informed at the meeting that this hospital was urgently required. We told the Minister we had no money. We left with a guarantee of £2,000,000—the very sum that Deputy O'Higgins mentioned here tonight—and the advice to proceed at once with the hospital. I had to call a special meeting of the Board of Assistance. We had the architect there and all the assistance we could get in order to prepare plans and specifications and send them up to the Custom House. Those plans and specifications are still hanging around and the old carrot is still being dangled by the Department of Health. Whenever we go forward for a grant for Saint Finbarr's Hospital, or anything else, the carrot is dangled: "But you are getting a regional hospital."

Now, all that was long before Saint Vincent's Hospital was thought of. I wonder what caused the change ? Why was it decided to spend the £2,000,000 earmarked for Cork in 1949 for this regional hospital on Saint Vincent's Hospital in Dublin in 1956? That is one of the things on which I should like to be informed. As Deputy Desmond said it is about time this carrot was buried. The people of this country have paid out of public funds £60,000 odd for paper plans for the Cork regional hospital. I do not know if we are a special benevolent society for architects or that public funds are there to be distributed to the professions in this manner, but this carrot has been kept in the Department and every time it is dragged out into the light of day, there are a few thousands more for the architect for a new plan.

It is time it were ended. Nobody wants it. In Cork there is a new sanatorium in Sarsfield Court and there are over 100 beds idle in that hospital at the present time. When we were moving patients from various hospitals to Sarsfield Court we were told that we would have to reserve beds there for patients from other counties. I think it was 50 beds for County Clare. Now we are left with all the beds empty. Are the various authorities to whom these beds were allocated paying for their proportion of the beds or is the Cork ratepayer paying for all? That is a matter to which the Minister should turn his attention because our rates are high enough. With the spectacle before us of over a hundred idle beds there, is it not time that some sanity should enter the Department of Health so that we could get rid of this bugbear of a regional hospital?

Would the Minister, the next time he is in Cork, take a look at the monument erected by the Department of Health over a number of years, a look at the heaps of muck piled up there, where weeds are growing on 32 acres, and consider that £60,000 of public money is buried there, and then ask himself what kind of Department of Health we have? When sensible suggestions are submitted to the Department of Health, such as Deputy Desmond alluded to here to-day, they are ignored. There are many disused buildings in Cork County which we are anxious to convert into homes for the aged and infirm who are at present in St. Finbarr's. I can boast that after a hard fight I succeeded in having kept in my constituency the only county home apart from St. Finbarr's left in Cork. I held it there in spite of all Governments and all Parties. The people are happy in it. It is far cheaper to keep them there than in St. Finbarr's. We have expended a pretty considerable amount of money on St. Finbarr's Hospital over the years. It is a first-class hospital in every respect to-day, with only one fault, and that is the question of accommodation for patients. If we could transfer the 300 aged and infirm people who are there to Kinsale and Youghal——

We do not want them.

——we would be in a position to provide accommodation in St. Finbarr's for our patients. Unfortunately, the Department of Health evidently wants another job for an architect. We were preparing a wing there for some 20 orthopaedic patients before the orthopaedic hospital was started. We got our own engineer to prepare plans and specifications for work costing £8,000. We got an order from the Department of Health to employ an architect, who, of course, is paid fees, based on every £1,000 of the cost. The more thousands he puts into the job, the bigger the fee. The cost of the plan and specifications prepared by him was £19,000. I can challenge the Minister to deny that we came to the Department of Health and told him we had plans and specifications for the preparation of this wing at a cost of £8,000 and that we had no more money and, rather than turn down the architect, we got the £11,000 from the Department. They were prepared to pay for the architect.

As Deputy Desmond has said, there will be changes here. This is the last year of this Dáil. A new Dáil will assemble here in the coming year and I will be missing a lot of the nice faces I see around me to-day when I come back. I should like this job to be finished. Neither the Minister nor the Department need hope that they will get rid of me. They will not. I am anxious that the job will be finished, that we can get rid of the regional hospital magpie. Let us get down to bedrock. Let them send the £2,000,000 to Cork together with the interest due on it since 1949, since the Minister guaranteed it to us, and let us provide decent homes for the people with the money.

I was amazed to hear Deputy O'Higgins here to-night. I know the Health Act has caused a great deal of trouble. I have witnessed various scenes here over the Health Act that many of us would prefer had never happened in this House. I have seen a poor Minister who brought in this Health Act, poor Deputy Dr. Browne, being harassed by two or three legal luminaries before he ran out and left Act and Ministry and all. Deputy O'Higgins told us about the Act brought in in 1953 and he demanded to know why it was not operated for eight years. He said there were no dental services provided and wanted to know why.

I have a faint recollection of being on those benches over there for a period and there was a certain Deputy Thomas F. O'Higgins a Minister for Health in 1954, 1955, 1956 and on until 1957. What was he doing at that time about the dental services which he said were not operated for eight years? The Act came in in 1953. What was he doing from 1953 to 1957 about the dental services if they were not in operation and if, according to him, they are not yet in operation ? That was the most amazing indictment that I have ever heard by a man of himself.

Deputy O'Higgins went on then to deal with the provision of spectacles. The same thing happened here and the same thing happened to disabled persons. All of these were covered in the 1953 Health Act which was not operated by the present Minister who came into office in 1957. There was a gap of three or four years during which Deputy O'Higgins was here as Minister for Health and did not do any of these things himself. That is what I am wondering about. The official report of Deputy O'Higgins speech would be well worth reading in that respect.

I do not know where Deputy O'Higgins got his information. According to my information, some 700 sets of dentures are provided each year in South Cork Board of Assistance area and if the Minister has neglected his duties and no dentures are being provided, who is getting all these 700 sets of dentures? That is something I should like to know. I know we are also providing spectacles in the South Cork area. As Deputy Desmond said, we may not be providing all the dentures needed and we might have a long list waiting for spectacles but we are providing them. In some way or other Deputy O'Higgins was up in the air. Does he think that the same bad game that he evidently practised, according to himself, is being carried out by the present Minister, that there are no dentures, no spectacles, no this or that as was the case when he was Minister ?

I admit, like Deputy Desmond, that certain managerial forces, I suppose, are working to deprive the aged people of the dentures to which they are entitled. It is about time that the manager got special instructions but we can move for the suspension of the manager and let the Minister deal with him. There is provision for dealing with the manager in that way and I should like all managers to remember that. The elected representatives of the people have a way of dealing with them if they go too far. Had it not been that one gentleman went away in time I think I would have done it.

Regarding medical cards, I say frankly that a considerable section of people who, before this Health Act was ever heard of, would be treated in the ordinary way and without question by the dispensary doctors are now questioned. I refer to the agricultural worker. Deputy Desmond gave the scale but I have seen an unfortunate man who as an agricultural labourer on a very poor wage reared seven children. During that time there was no Health Act and he was entitled to health services for himself and his family from the dispensary doctor in the area without question. If there was any question, he got a ticket from me and got the services. At present he is not entitled to services.

They now say his wage is over £6 or at least the accumulated wages of himself and his family are over £6, and therefore he can get nothing. You will hear this kind of statement : "This man has a daughter working in Glanmire getting £2 a week." That, added to the £5 odd that the man earns, brings up his wages. You will also hear it said : "He has a son working who was thinning turnips last week and got 35s." That is added in. All those things are added together to deprive the man of his right to get a card.

We all know that in the case of young people at the present time, if they are earning, their families get very little, if any, money at home. The fathers and mothers cannot make them give it. There is no use in pretending they can. I have seen some cases of this where, since the doctors got wise, or since those new medicines came out, there is a bill of 35s. a week for pills and there are not very many pills in the box you get for 35s. I think this is all grossly unjust and, as Deputy Desmond said, I do not think the members who voted for that Act voted for the manner in which it is at present being administered.

What is the position in regard to the distribution of the Government grant in respect of free boots for Cork county? What is the position as regards its administration ?

I think that comes under the Department of Social Welfare.

I do not think it arises on this Estimate.

I shall look forward to a pleasant time on that Vote.

I make a last appeal to the Minister to let us have some decision on the regional hospital in Cork County. I was surprised to hear Deputy O'Higgins asking about the £2,000,000 he was going to give to St. Vincent's Hospital. The last decision we had from the Minister was that there was no money available for seven years for the regional hospital and that the £2,000,000 that was guaranteed by Deputy Dr. Browne when he was Minister for Health in 1949 was not there at all. We want to know some time where we are. When the South Cork Board of Public Assistance representatives send up to the Department for grants to which they are justly entitled, let us have this carrot of the £2,000,000 for the regional hospital no longer dangled under our noses and given as an excuse for giving us nothing.

As a matter of curiosity I would like the Minister to bring his team of officials down to Cork. I will guarantee him decent treatment and a hearty welcome from the Cork representatives. Let them go out to Wilton and look at the graveyard of the £60,000 they have buried at the regional hospital there.

May I say I have seen some very good work done under the Health Act? I have seen children who would probably be invalids for the remainder of their lives, were it not for that Act, being sent to hospital where the best medical services were made available to them and being returned home fit boys and girls able to take their place in school and in the community for the remainder of their lives. That is a tremendous benefit conferred by the Health Act.

However, we as public representatives do find ourselves sadly disappointed in regard to the operation of the Health Act. As councillors and Deputies we are expected to be able to put through various claims made by parents and when we approach the authority concerned we are told those people are not eligible. No later than last Monday I was approached by a married couple who were living with one of their parents in a house whose valuation was £12 or £14. They had a family of six and had sent their little girl to hospital in Dublin at their own expense. I should like to ask the Minister if that child is entitled to treatment in hospital free of charge under the Health Act, because the child is only 12 years of age.

The problem of dispensaries is one that should be carefully considered. A circular was sent out to the local authorities some time ago asking that, where at all possible, dispensaries be closed and the services of the doctor in the area be terminated. That would have happened in my county if it had not been for the protest made by the people who asked that the dispensary be kept open. A dispensary is very important to a great number of people. A large section of our people depend on the dispensary doctor and the dispensary itself and if this service is taken from them it would be a terrible loss to these people.

Approaches are often made to us in respect of the provision of dentures and spectacles and also in relation to the blind pension. The blind pension is one of the hardest things for an applicant to obtain. Many people are unable to qualify for a blind pension, although they may have no employment and are able to do very little because their eyesight is seriously impaired. They have to go through a gruelling test.

That would be relevant on the Estimate for Social Welfare.

I should like the Minister to take note of the fact that these people must undergo a gruelling test when they go before a doctor. Another matter to which I want to refer is the question of water supplies and hygiene regulations. I seem to be out of order again. In referring to mentally-retarded children I hope I am not out of order.

The Deputy is doing fine.

The problem of mentally-retarded children is a serious one in my constituency. Public representatives and clergy are constantly approached to have children placed in some of these homes where treatment is afforded to them but the only answer they get is that there is a long waiting list. The other day the first sod was cut prior to the building of a hospital in my constituency and I was told that it would be 1964 before the hospital would be completed. I would ask the Minister to do his utmost to provide accommodation and treatment for mentally-retarded children. It is a very serious matter that many of these children must be kept at home with the other members of the family.

The Minister spoke for quite a long time, about an hour and twenty minutes, and during that period he gave some quite interesting statistics. I was disappointed with one aspect of the Minister's speech—the almost cursory reference he made to cancer. Beyond stating that 4,700 people died of cancer last year the Minister ignored this second highest killer almost completely and, if I recall correctly, the same thing happened in regard to his speech last year. I would have thought that, as the question of the treatment and diagnosis of cancer comes within the ambit of his Department through the Cancer Association of Ireland, the Minister would have availed of the opportunity today to tell us something of what is being done by the Cancer Association in particular and what efforts are being made to find an answer to this dread disease. I quite appreciate, and I know from my own past association with the Cancer Association in St. Luke's Hospital, that the treatment of cancer, and particularly the effort to find some way of stopping cancer, is something that takes a lot of money.

Cancer research runs into millions of pounds and it takes very wealthy countries such as the United States and Great Britain to amass the necessary personnel to undertake research to any degree. But small countries such as our own have made valuable contributions towards finding a solution of the cancer problem. Some three or four years ago an effort was made by the Cancer Association to undertake cancer research based on statistics collected from doctors in hospitals throughout the country. These statistics related to the type of cancer from which the patient died, the place they lived, the environment, type of employment and other details which, collected together and properly analysed, would, it was felt at the time, have given valuable information to those seeking a solution of the cancer problem. I do not know what happened that development. I no longer have any associations with St. Luke's Hospital. Certainly, when this research was established there were high hopes it would prove, if a small, certainly a valuable contribution to the general problem of cancer research. I hope the Minister when replying will be able to give the House some information as to what has happened in regard to that matter.

I was glad to hear the Minister mention in his speech that at long last the cobalt unit is to be installed at St. Luke's Hospital, where it will be available not only for patients attending that hospital but also for those attending the other Dublin cancer hospitals. Those of us who several years ago expressed the hope that one day this country might have a cobalt unit will be glad of this news.

I should like to make some comments on the question of dispensary services which the Minister dealt with at some length in his speech and which were adverted to by Deputy T.F. O'Higgins. I must say I agree with Deputy O'Higgins's wish that the dispensary patient would have a choice of doctor. I agree with the Minister that this may be difficult in practice but I am not convinced it is insoluble. I think, given the necessary goodwill, it should not be beyond the resources of the Minister's Department to devise a system whereby a man, a woman or a child should be able, within reason, to seek the doctor of his or her choice. It is wrong in principle that this choice of doctor should be confined only to those who can afford to pay. I am sure the people who devised the 1953 Act had it in mind that at some future date choice of doctor would be an integral part of the system.

It is time we thought about getting away from the whole idea of a dispensary service as such. The very name "dispensary" is associated with a past period of our history which we would rather forget about than remember. In talking about the dispensary service we should associate it more closely with the giving of social welfare benefits rather than with health services. I should like to see the health services developed through health clinics that would not be associated with the giving out of public assistance funds. I feel they are two distinct services and should not be combined together in the same building or even sections of the same building. The dispensary buildings we have throughout the country —many of them old and all of them uncomfortable—in the winter time when these unfortunate people have to queue up and wait either for the dispensary doctor or a pittance in the shape of public assistance, do little credit to this year of 1961.

The ideal would probably be to have properly staffed clinics with specialists available. Deputy O'Higgins and Deputy Desmond, I think, referred to the fact that there seems to be a growing tendency now to pack people off to specialists, even for the most minor complaints. If the specialists were available close to the patient's family doctor, it would be a far better system than packing them off to already overcrowded hospitals.

Several Deputies made references to the dental services. I know it is the desire of the Minister, as it was of his predecessors, that the emphasis in dental services should be placed on preservation and conservation of teeth. I am in wholehearted agreement with that point of view. If the dental services are carried on as in present circumstances, that desire of the Minister, particularly in regard to dental services for children, will never be carried to fruition. It is quite impossible with the present number of dentists—certainly in my own constituency and particularly in Limerick city—to hope to give an adequate service to the number of children, particularly school children, who should attend and have their teeth seen to at an early age. I hope the Minister will look more closely into this side of the problem than he apparently has done in the past.

I think it is completely wrong—I do not know what the statutory obligation is—that a person who cannot afford a set of dentures has to wait perhaps a year or two years before getting them. Any public representative knows of many cases where a person's teeth have been extracted and they have to wait two years before they could get dentures. The excuse given is that there are not sufficient dentists to look after the children's needs and also the needs of adults who cannot afford to pay for dental services themselves.

I was also glad to hear the Minister say that at long last he has sanctioned an extension to St. Vincent's Home for child mental defectives at Lisnagry, Limerick. This is a long outstanding need. Despite a very severe shortage of beds, the work carried out there by the Sisters of Charity of St. Vincent de Paul is remarkable. I am personally aware that although the bed accommodation is less than 40, they have never had less than 150 children seeking admission to the institution.

It may be too soon for the Minister to say something about the operation of the joint health authorities but, if he has any information at his disposal, I think the House would welcome some information as to the success of the joint health authorities, particularly in regard to the services given and the economies which the Minister visualised when he was introducing the Bill a year or so ago. I think I am correct in saying the Minister made no reference in his speech to the working of the Voluntary Health Insurance Scheme. That is a scheme for which I have a great regard.

There is no provision for it in the Estimate and, therefore, it would not be proper for me to refer to it in my opening statement.

I think I am correct in saying that in past years the Minister has made reference to the Voluntary Health Insurance Scheme. However, it does not matter. The Voluntary Health Insurance Scheme is a scheme that seems to be succeeding. I am sure the Minister wishes it every success. I do not know how far we could go along the road of providing limited health services confined to certain income groups. Every public representative has had experience of complaints about the issuance of medical cards.

Hear, hear!

There do appear to be inexplicable differences in the issuance of these cards to different families. It is often hard to understand why one family cannot get a medical card while another family, with comparable income, enjoys this facility. It is, I know, too much in present circumstances to expect the country to consider a completely comprehensive national health scheme. I have a feeling that, once you step on the road of giving services to those who need them free of cost, inevitably you must face up to bringing in at some time or another a comprehensive scheme covering practically all classes. I know that would be a very expensive scheme and probably one we could not afford but, until we have some all-embracing scheme, public representatives are bound to get constant complaints from people who feel they are not getting that to which they think they are entitled.

Lastly, I should like to make reference to a section of our health services to which no reference so far has been made here to-night. We have heard references to the doctors, and to the Ministervis-à-vis the doctors, but there has been no reference at all to the nursing profession. I should like to say a word on their behalf. Recently misgivings have been expressed with regard to the reward which nurses get for their work. We have all at one time or another come in contact with the work of this body. If ever work was a vocation that of nurses certainly is. I should like to join with others outside this House who have appealed to the Minister to consider better remuneration and conditions for the nursing profession.

It is a fantastic situation—I think even the Minister will agree with me in this—that the Minister for Health in this country should not be talking to the only body that represents the entire medical profession in Ireland. The Minister says it is their fault and they say it is his fault, but can we conceive any other man in the public life of this country spending four years as Minister for Health in a situation in which he cannot exchange common courtesies with the representatives of the medical profession? I cannot help feeling that, if the Minister ever searches his own conscience, he must feel that in some measure he is falling down on the job. Surely the Minister for Health cannot be doing his job as it ought to be done if he has cut himself completely off from the practising medical profession of the country.

In a quarrel somebody must always take the initiative to put an end to it. If the Minister's thesis is true that the Irish Medical Association is altogether unreasonable, does that not throw all the greater burden upon him to demonstrate to the country at large that he is prepared to go, not only half way, but even further, in order to establish normal relations with that body? If he had done that, I think that demonstrably the force of public opinion would operate very quickly to make anyone who sought to continue to act unreasonably to desist. But the reason that no such public opinion has manifested itself is that the bulk of our people do not believe that the fault is all on the side of the medical profession. They believe that a great deal of the fault is due to the notorious vanity of the Minister. Now that would not be a reasonable allegation to make against the Minister if one were not prepared to produce some visible proof of it. When the Minister proceeds to employ anonymous stooges to write anonymous letters to the paper saying they think he is perfectly right, signed“Pro bono publico”——

Produce one of those.

I do not know that the pseudonym“Pro bono publico” was ever employed, but when you find a man in the position of the Minister hiring stooges to communicate to the Press proclaiming him to be a valiant man, but yet carefully eschewing the responsibility of defending their proposition as a logical argument, that seems to me to breed the air of vanity and effrontery.

Is that the type of speech that will help to bring about peace between the two parties, I wonder?

I have been trying to bring about peace for four years. Long experience has taught me that after you have sought to reconcile the irreconcilable for four years, and failed, then the time has come to remove one of the contending parties so that the nation can get on with the job.

There are two parties in it.

There are two parties. There was never a dispute without at least two parties to it.

There is nobody here who has ever chastised anybody except the one Party anyway.

I think the time has come when the dispute should be resolved in the common interest. I think Deputy Killilea will agree with me that the Minister for Health is not going to resolve it. Is not that a deplorable situation? If he is not able to resolve it, then his course is clear—to make way for someone who is.

If he is unwilling to resolve it, surely that would suggest he is allowing his vanity to override his responsibility. Whatever the cause, even the Minister, I think, will agree with me that the present situation is utterly deplorable. It is not in my power to resolve it; it is in the Minister's.

But not in the power of the Irish Medical Association to resolve it?

Of course, they must make their contribution but I think the initiative must come from the Minister.

The initiative did not come from me in starting this quarrel.

I suppose there never was a breach of promise suit, never mind a divorce, that did not find its way into the courts as a result of both parties saying: "It was not I who started it." Nor was there ever a skull cracked or an eye blackened that the fracas did not begin because somebody said: "It was not I who started it." Most people will agree that eyes do not get blackened or heads cracked when one party to an altercation is a responsible man because he usually at some stage of the quarrel preaches reason and says: "Now, you have been unreasonable and have used language which I regard as grossly offensive but let bygones be bygones and let us get on with the job. Maybe there are some things that we will not agree about but let us find the things we can agree about and get on with them." One thing is certain—could I get agreement on this proposition?— we cannot contemplate an eternity in which the Irish Minister for Health will not speak to the Irish medical profession.

Many members of the medical profession have come and seen me about their grievances and the disabilities under which they are labouring. They are the medical profession, not the Irish Medical Association——

Individuals.

——which does not represent the Irish medical profession, or even one-third of it.

This is the cheerful language of the benevolent autocrat but, of course, in this troubled democratic world in which we live, autocrats, however benevolent, are not acceptable. It has become the recognised right of a free society with professions and trade unions, that men shall have the right freely to organise and to choose their own spokesmen. I have often had to negotiate with trade union leaders, both in my public capacity and in my private capacity, whom I did not like but we were able to say to each other quite specifically: "We are under no illusion. You do not like me and I do not like you but I happen to be Minister for Agriculture and you happen to be the person chosen to speak for the employees in this particular branch of the Department. Let us forget our mutual dislike and see how far we can go to resolve the issues joined between us." It is possible to do it. There is no need to love everybody with whom you have to transact business. If that were the case, very little business would ever be done. Is it unfair to say that it is also an indication of vanity if a man is prepared to negotiate with nobody who does not first protest that he loves him?

The Deputy gave a good demonstration to the milk suppliers when he was dealing with them.

Upon my word, I think I did. In any case, no one can ever say I refused to meet them. Even when Deputy Killilea and a few of his colleagues persuaded tens of thousands of them to come up for a holiday and march up and down outside the Department, I did not get up on my high horse. I invited them to come in and see me, and I frequently did.

You brought them in to tell them they were daft.

The important thing is they never ceased to come and see me. We often did not agree but up to the very day I left office, it is true to say that representatives of the Irish Creamery Milk Suppliers and various other agricultural organisations came to see me. We often disagreed and doubtless Deputy Killilea got some of their branches to pass resolutions violently critical of me.

I had no association with any branch of the creameries at all.

The question of creameries does not arise on this Vote.

I think the Deputy will agree with me that at all stages I was prepared to meet them and talk to them and discuss their difficulties. That is all I want the Minister for Health to do.

You never solved their problems.

At least I tried and was prepared to discuss them with them. I am not saying the Minister can be required to announce in this House that he has resolved every problem presented to him. All I am asking him to say is: "If they have a problem, I will discuss it with them and, if they do not like me and I do not like them, that should not operate to prevent us discussing their problem because it is my obligation as Minister for Health to seek to resolve it and if I fail, it will not be for want of effort."

They put themselves into an impossible position and will have to extricate themselves from it. That is their problem.

I think that is the language of a vain man.

That is their problem.

It is the language of a foolish little autocrat because the Minister will find out to his cost, in the last analysis, that will not be the verdict of the public. I do not think the public will long stand for a Minister who says: "That is their problem. They have got into the difficulty and let them get out of it. I wash my hands of it." That is not, if I may say so, with respect, what the Minister is paid for. The Minister is a paid servant of the public and that is a proud title.

And has a duty to see that the public services are carried on and that they are being carried on very satisfactorily.

That is a matter into which I propose to go in the remaining quarter of an hour. I think they could be carried on very much more satisfactorily if there were reasonable relations between the organised medical profession and the Minister for Health. I do not think the Minister should lay it down as a condition precedent to such relations that the doctors should choose people whom the Minister likes to represent them in any discussion that may be requisite. That is an unreasonable condition. No rational body of men, whether they be labouring men or professional men, will ever accept it. When that is a condition precedent, there never can be the proper relationship between the Minister and the medical profession that ought to exist.

I want to refer to a matter about which I feel deeply: The Minister is now embarking on a distribution of Hospitals Trust Funds for the erection of St. Vincent's Hospital and certain other hospitals. I want to say most categorically that I am convinced that the policy of the Minister for Health in holding up the building operations of those hospitals was dictated by a pure desire to play politics and I believe it has had two results: (1) it has denied to a great many of our people services which they had a right to enjoy; and (2) it has driven thousands of workers, skilled and unskilled, into emigration during the past four years. I think the Minister will agree that, in 1957, there was a high incidence of unemployment in the building trade. Are we not all agreed on that? We remember the Fianna Fáil Party making ghoulish propaganda. Is that not so? They were rushing around the country——

They were telling the truth.

Yes, that there was higher unemployment in the building industry. Was that not the truth?

Do you remember Deputy Briscoe?

Deputy Loughman asks: "Was it not the truth?" I agree. The truth was there was high unemployment in the building industry. It is very typical of Fianna Fáil that the Deputy does not know what the truth was but, whatever it was, he was telling it. That is an exact definition of Fianna Fáil truth. He did not know what the truth was but, whatever it was, they were telling it. That is the Deputy's degraded propaganda, his ghoulish glee, at the unemployment then existing in the building trade.

At that time, plans were sanctioned for St. Vincent's Hospital, the Coombe Hospital, Erinville and other hospitals that would have involved a very considerable volume of employment in the building trade, skilled and unskilled. You would have tided over a number of skilled workers until other buildings of a mercantile kind revived and you would have kept them in Ireland with their families. I say that the Minister for Health, purely for political reasons, operated the same confidence trick that Deputy Noel Lemass operated in Dublin Corporation. Was it Deputy Noel Lemass or Deputy Briscoe?

What has Dublin Corporation to do with it?

I shall tell you. It was all part of one dirty conspiracy to create unemployment in the building industry. The Fianna Fáil Party closed down the building industry.

We are not discussing the building industry.

I am alleging that the Minister's decision to postpone the building of these hospitals was primarily designed to create unemployment, to postpone their erection until in fulfilment of his own base political motives he could present, on the eve of a general election, a picture of liberal distribution of public money—and I shall prove it. I now allege that he had in his office on the day that he entered it plans to build four substantial hospitals——

And no money.

Wait a minute. I allege that he deliberately cancelled those plans and that he offered the same rotten, dishonest alibi for the decision that Deputy Noel Lemass offered when he refused to agree to issue grants for Small Dwellings Acquisition Loans for Dublin Corporation although he was guaranteed £5 million to provide these grants. His reply was: "Not one penny until the money is put on the desk." This Minister for Health replied that not a penny would he authorised to be hypothecated for the building of these hospitals unless and until the money was in the till. It is quite true to say that the Minister could say: "Maybe the Irish Hospitals Sweepstakes will blow up in the morning and that everything will go bang." If that philosophy underlies Government finance, we should close the country down and announce that we rest confidently on the bosom of the British Treasury who will see us through the trials that will come. That was not our policy. Our policy was to say that we had the means to do what was necessary for our people's welfare——

Where was the money?

Did we not house them?

Did we not build sanatoria Fianna Fáil said they could not afford to build?

That is completely untrue.

Did we not build the houses and the hospitals? Did we not take the people out of the slums and provide accommodation to cure them and did we not find the money in the heel of the hunt? But there is the silly, cheap, fraudulent mind of Fianna Fáil who, I have no doubt, have sold to some of their more innocent backbenchers the proposition that you cannot build houses in this country until you have the money in the bank but that you can go down and buy a television set, if you are earning £8 a week —or if you are earning nothing a week —instal it in the house and pay for it out of your weekly income. But the nation was to be told that although every individual in the city of Dublin and throughout the country can buy television sets on three years' credit you cannot build one hospital wall unless you have money in the bank.

Until you restore your credit. That was the problem— to restore what you had destroyed.

It was a mean thing to drive thousands of our people into emigration in order to serve that dirty political trick. Remember 200,000 have gone in those four short years and this nation has lost more men and women than many a country has lost in the course of a long war. I believe those that are gone from us are not dead but, economically, from the point of view of Ireland and socially from the point of view of our society, of which they constituted a part, they are dead to us——

They have gone to their reward.

No, thank God. Fianna Fáil did not kill them. They only drove them from their homes but it is no thanks to Fianna Fáil that we cannot rattle their bones; it is thanks to the employment they found in England and America but that is not a boast Deputy Loughman ought to make. Oliver Cromwell never aspired to drive the people further than Connaught; it took Deputy Loughman to drive them to Birmingham and Brooklyn.

As usual the Deputy is——

Is that not true? Is it not true that they have gone since the Deputy sat on that side of the House?

Deputy Dillon seems very happy about it.

No, I am not, but I am saying that the responsibility for their departure will be firmly fixed where it belongs. I have a certain respect for sinners who do penance but for whited sepulchres I have nothing but contempt. You did it for political advantage and you will be made to face the people to whom you did it, in all the nakedness of your disreputable activities.

Let us get back to the Estimate.

That is the Estimate. It was the Estimate to drive the workers out of the country to the point where the Minister is now in the embarrassing position that he finds it hard to get the skilled workers necessary to allow building to proceed at all. That is due to the fact that he wanted to make his little contribution to fool Deputy Loughman and poor Deputy Geoghegan into believing that Ireland, of all the countries in the world, could not afford to build a hospital wall because she did not know where the money would come from.

It is not the first time that Fianna Fáil has gravely injured this country by doubting its survival and there is no greater injury that you can do a country than to raise, as a political campaign, the scare that your own country cannot survive. This country survived long before the name of Fianna Fáil was ever heard and it will be here long after they are forgotten.

We are travelling away from the Estimate.

Hear, hear.

I welcome that signal of assent from the battered ranks who uttered it but they cannot deny that, if the Minister had made available from the Sweepstakes Fund the money to build these hospitals, thousands of young men who are to-day building in England could, and would be building in Ireland and hundreds of patients who are doing with second-class accommodation could, and would be having the best in their own country. I do not think that is anything to be proud of and I think the Minister might well hang his head in shame.

Progress reported; Committee to sit again.