Dáil Éireann debate -
Thursday, 15 Jun 1961

Vol. 190 No. 3

Committee on Finance. - Vote 54—Health (Resumed).

Debate resumed on the following motion:

"That the Estimate be referred back for reconsideration."—(Deputy T. F. O'Higgins.)

Mr. McQuillan

I had pointed out before Question Time that it was encouraging to see the change of mind— I do not say it is on the part of this Minister—with regard to the necessity to give a choice of doctor to people who come into the dispensary service category. Whatever happens in future, that is on record and it is a step forward, so that there is hope, in that whatever changes may take place in the political field, we have a promise there to have the necessary steps taken to improve, in that connection at any rate, the very inadequate health services or medical services available in the country.

As I have said, while some of us have a grievance, it is our duty to see that the best possible work is done by those services, even under the restrictions that exist at the moment. Even though sympathetic consideration is given by the county manager in Roscommon to the majority of cases, I have found that his hands are tied with regard to the reduction or complete remission of hospital bills. I should like the Minister to examine one particular case which I propose to bring to his notice here and now. I feel that if this case is examined properly, the Minister will find it essential to bring about changes in the existing situation.

I have here with me a hospital bill given to a small farmer in County Roscommon, by a voluntary hospital, where his wife went to have a baby. Unfortunately, both mother and baby died in the hospital. I want it to be quite clear that what I have said in this House I have said outside already and will say outside again, if necessary. There is no question of seeking the protection of the House for the statements I am going to make. This man's wife became ill and, on advice, he sent her to the voluntary hospital as a semi-private patient. He was advised that she would get better treatment as a semi-private patient. Although a voluntary hospital, this hospital has arrangements with the local authority in Roscommon to take the overflow of patients which should normally go into the County Hospital. The arrangement to pay for patients in the voluntary hospital exists between the county council and the hospital.

I want to emphasise that this lady was only two days in the hospital. During that period, she was seriously ill, haemorrhaged severely, and died. So did the baby. I doubt if any Deputy or anybody in the country could estimate, or make an accurate guess, as to what the hospital bill was that the unfortunate husband received after the deaths of his wife and child. The bill, which included drugs, plasma and hospital maintenance amounted to £77/7/9 for two days. I think it would be only fair to have on the records of the House what the bill was—two days at the rate of £7/7/0 per week, £2/2/0; theatre fees, £2/2/0; drugs in theatre, £1/1/0. There were a number of pathological laboratory tests, one of which cost 10/- and the second of which cost £3/5/0. There were 11 pints of blood at £2/2/0 per pint, £23/2/0. As an extra, there were 9 pints of plasma at £4/4/0 a pint, amounting to £37/16/0. There were 1 pint of saline, 6/4d.; 6 pints of dextrose, £1/19/0; luminal, 2/2d. and medicines, pethedene and hydrocortisone, amounting to approximately £4/11/0. To crown it all, there were mortuary expenses of 10/6d.

In addition, the unfortunate man received a bill for £12 12s. from the doctor who operated on his wife. He made representations to the doctor and, as a result, the doctor graciously reduced his bill to £10 10s. The entire bill for hospital expenses and the doctor's fee amounted to 3d. short of £90, a rate of £45 per day under our famous Health Act.

Mr. MacEntee

The Deputy might disclose the fact to the House that this lady was a private patient.

Mr. McQuillan

I have made it clear that the lady went in as a semi-private patient into a semi-private ward and did so because her husband was told that she would get better treatment by doing so. That is being said to patients all over the country in every voluntary hospital and by every doctor associated with voluntary hospitals because that is where they get fees and that is where the hospitals themselves will have full power to take the last penny. This is the greatest condemnation of the present set-up that I know of—to think that a man with 21 acres of land is supposed to pay £90 for the death of his wife and child.

This matter was brought to the notice of the local authority and the local authority in Roscommon unanimously recommended to the county manager that the entire bill be cancelled in this case. Members of the Minister's Party spoke strongly at the council meeting on this matter. The manager's decision was that the local authority should be responsible for £38 12s. of the bill, leaving this man with responsibility for paying the remainder, £38 15s. 9d.

Let me make it clear that this man was entitled to a medical card on his valuation of £12. He had not applied for a medical card at the time. We all know many people do not apply until they actually need it. In spite of the fact that he was entitled to get medical card treatment, the most the local authority could do was to reduce his bill by 50 per cent. This, I presume, was due to the faulty arrangements made under the Health Act with this voluntary hospital.

Mr. MacEntee

No.

Mr. McQuillan

I know by the Minister's interjection that the Minister has been warned about this.

Mr. MacEntee

I had this case long before the Deputy had it.

Mr. McQuillan

Yes, because I brought it to the notice of the county manager in Roscommon.

Mr. MacEntee

No, before that. The gentleman wrote to me himself.

Mr. McQuillan

He may have done so. One of the things I told him was to get in touch with the Department immediately. I am not seeking political credit out of it.

Mr. MacEntee

It seems to me the Deputy cannot seek political credit out of it.

Mr. McQuillan

The Minister should have his head bowed, ashamed of his life that such a thing could happen. The suggestion has been made that the Minister is acting as the mouthpiece for the people who prompted him to deny that this patient was anything but a private patient. This lady went into a semi-private ward on advice given to her husband.

Mr. MacEntee

Advice given by whom?

Mr. McQuillan

The Minister is not going to get me to name any individual.

Mr. MacEntee

The Deputy was very brave when he said he would repeat all this outside.

Mr. McQuillan

I have not even named the hospital. I would prefer the Minister to do so now.

Mr. MacEntee

The hospital denies the allegation the Deputy has made.

Mr. McQuillan

Will the Minister name the hospital?

Mr. MacEntee

The hospital denies the allegation the Deputy has made.

Mr. McQuillan

I am sure the Minister's sight is quite good. I have a bill here in my hand and it mentions £77 7s. 9d. He also has the letter from the man himself, in which he states—I shall make it available to the Minister immediately after the debate—that his bill from the doctor who attended his wife was £12 12s. and that, as a result of putting his case before the doctor and telling him of other misfortunes that had happened to him on his farm, he could not pay £12 12s. and that the doctor graciously reduced it to £10 10s. Does the Minister deny that is accurate? Is the Minister suggesting that it was not £45 per day?

Mr. MacEntee

I am merely suggesting that the Deputy is misleading the House by suppressing the fact that if this patient had gone into a public ward, as she was entitled to do, she would not have been charged anything.

Mr. McQuillan

I merely want the Minister to say now if it is true, or in accordance with the facts, that the bill for this lady, whose husband was entitled to a medical card and who went into a semi-private ward because of his belief that better treatment would be given in a semi-private ward, was charged at the rate of £45 per day for two days? Is the Minister suggesting that is inaccurate? I am glad he has realised it is not. Will the Minister say why it is impossible for the county manager to be more lenient or to stretch the Health Act a little further and at least relieve him of this financial burden in view of the exceptional circumstances? Nothing can be done to relieve the dreadful loss of his wife and child.

Can the Minister do anything to have this bill remitted? Will the Minister tell the House what kind of arrangements are in operation under this Health Act which allow that to happen anywhere in Ireland? Is it not a fact, if the Minister is making his stand on a technical point, that a doctor in that hospital had only to put his name on a piece of paper certifying that, due to the condition of the lady, it was essential that she should receive treatment in a semi-private ward? If a doctor had written that down, there could be no charge at all. Was that done? Of course it was not. If it had been done, this man would not have been charged £77 7s. 9d. by a voluntary hospital.

Roscommon County Council have made arrangements, as I understand, to pay approximately half of that bill. Is it not a fact that the remainder of the bill will be borne by the public because are not the losses of voluntary hospitals met by the State? Why should this man be asked to pay in these circumstances? Surely in the circumstances the hospital could have said: "You have lost your wife and child. We think that is sufficient without asking you to pay this bill." I shall send the bill to the Minister and I hope he and his Department will take the necessary steps to ensure that it is cancelled completely. I do not care how he does it. My advice to the man concerned is: pay nothing, absolutely nothing in the circumstances. I want the Minister to make investigations to ensure that this type of practice will not occur again.

A number of other matters arise from this bill about which it would be no harm to let the House know. How is it that the cost of blood, for instance, is so high? I do not blame the hospitals themselves for the charge. Plasma works out at four guineas per pint. I should like the Minister to tell the House why it is that price. I should also like him to tell us why it is that blood works out at two guineas per pint. I am a layman but I understand that blood is donated on a voluntary basis and that the most anyone gets for it is a bottle of stout. How do we reach the figure of two guineas for a pint of blood? Is it due to the processing? If it is, I should like the Minister to let the public know the position. If that is true, is there not a case for putting a control on the price of blood as well as drugs, antibiotics and so forth?

That brings me to a point stressed by Deputy Dr. Browne here today, the cost of medicines and drugs, and so forth. I see that in our neighbouring country, where there is a conservative Government at the moment which is far more to the left than the Fianna Fáil Party, they have decided to institute inquiries into the cost of the manufacture of drugs. In the meantime, pressure is being put on all those companies which are mainly American-owned to reduce costs. The British Government are not satisfied to wait until legislation is passed. Under the National Health Services, the British hospitals are now purchasing their requirements direct from Italy. I understand that in Italy the cost of drugs and antibiotics is often 50 per cent. to 75 per cent. less than in Britain.

If a publicly-owned hospital in Britain can reduce the heavy costs of drugs by adopting that method, why can our Government not do the same? Surely when a good example is set, no matter where, it is no harm for us to emulate it. It is a much better proposition for the purchasing branch of the Minister's Department to buy in bulk from Italy, or any other country, and make these drugs available so that the high cost of medicine will not be borne either by the individual or the State. The Minister was crying about the present cost of the health services. Here is a practical way by which he could reduce costs and increase efficiency at the same time. I suggest that he should get cracking on this matter as soon as possible.

I should like to join with Deputies from both sides of the House in urging the Minister to take immediate steps to improve both the salaries and conditions of service of the nursing profession. Beyond contradiction, the nursing services are vital to the success of any health service, but over the years their services have never been really recognised in this country. Through their association, doctors have been a very powerful body indeed but I have never yet noticed that they helped the nurses in any major issue. The doctors attached to the local authority hospitals received a substantial increase in their salaries recently. I am not making any comment whatever upon that increase. I understand that in many cases it amounted to about £360 a year. We should remember that the nurses and indeed the sisters and staff nurses are probably paid that amount. The increase offered to them, in comparison with the increase offered to the dispensary doctors, was, I understand, in the region of £10. I think that was a most unfair increase to offer to one of the most important branches of the profession which looks after the health of our people. The Minister should have another look at that matter.

I know that recently he pointed out that the country cannot afford it, that it would cost around £1,000,000. I shall not elaborate on the things on which we spend money and point out where savings could be effected. I say it is essential, if we are to have a proper nursing service here, that we should pay our nurses and give them good working conditions. My advice to them is to form the strongest possible trade union because as they are at the moment — they are disunited — their power to bring their efforts to fruition is very limited. It is notable that any organised group, properly led, can work miracles to improve its conditions. Nurses have been completely disorganised and even the body which purports to represent their interests has been completely inefficient over the years. There has been a change there recently. I think there is great hope that the present group who are interesting themselves in the nurses' organisation will continue and persevere in their efforts until success is achieved. I want to make it clear that the example is there for the nurses in regard to what a union can do.

The I.M.A. in recent months have carried out an inquiry amongst their own members as to whether or not they consider it desirable to form a trade union. I understand that, as a result of the inquiry, a majority of the doctors——

Mr. MacEntee

A minority.

Mr. McQuillan

A minority? I understand that the majority of the members of the I.M.A. have voted in favour.

Mr. MacEntee

A minority of the members. One-third of the members of the I.M.A. voted in favour of that proposition. A number voted against. The Deputy ought to have read the bulletin from the I.M.A. very carefully and he would see what was involved.

Mr. McQuillan

I did not see the bulletin the Minister refers to. I was under the impression that a number of members of the I.M.A., who had a bit of sense knocked into them, had agreed to the idea of forming a proper union. If that is not correct, it still does not take away from my argument that it is a desirable feature and something that the doctors themselves should do. I think the nurses, if the doctors do not do it, should set the example themselves so that they will be in a position to argue with Ministers who are as hard-hearted and as flinty-hearted as the present Minister is when it comes to dealing with their position.

They are entitled to arbitration. They are entitled to the same facilities as are given to the officials and servants of the State. The Minister should not in any circumstances take advantage of the fact that these girls are so devoted to their profession that they still carry on under adverse conditions in helping to look after the sick. The fact that they have never taken any action in regard to slowing up, or action of a punitive nature against the Department and the fact that they have always been loyal to the patients in the hospitals should be far more appreciated than it is.

Of course, as the matter stands now, conditions abroad have become so attractive that our hospitals here find it almost impossible to become properly staffed. The law of supply and demand, if there is such—and we hear a lot about it—in this instance is going to favour the nurses. It is a tragic thing that it is the pull and attraction from abroad that will force this Minister or the next Minister—if the present Minister does not come back—to alter the situation with regard to the nursing service.

Again, just let me say one word on the question of the powers the Minister has under the Health Act. I saw recently where a number of companies advertised their products on Radio Eireann. I listened on a number of occasions to various companies on the sponsored programmes telling us what wonderful products they have. I should like to refer to one product that might come under the Minister's control. We dealt here today with dental care. There is a company at the moment—the Colgate-Palmolive company — which claims regularly in its sponsored programme that their toothpaste protects users against tooth decay. Now, I wonder is that accurate?

I would say this to the Minister and other members of the Government who are always looking across the Atlantic to see what they are doing in America and saying it is a wonderful country. In America, in 1959, the Federal Trade Commission charged a certain company with improper advertising and ordered Colgate-Palmolive to stop claiming that its toothpaste prevents tooth decay. That action was taken in 1959 in America. That same company is advertising here on Radio Eireann making a claim they were prevented from making in America. Will the Minister take action to stop that type of dishonesty on the part of that company? I know there are other companies for which the Minister has no responsibility but for which the Minister for Industry and Commerce is responsible. I propose asking some questions on that Estimate. Will the Minisster, in view of the fact that this toothpaste is alleged to have a bearing on health, look into the matter as soon as possible?

I want to conclude by asking the Minister whether he is prepared to take any action on the request made to him recently by the Roscommon County Council with regard to increasing the normal health grant of 50 per cent. to 60 per cent. I have here a copy of the minutes of the council meeting at which this matter was discussed. The Minister has a copy of the letter in his files. I should like the House to realise the position in County Roscommon at the moment after the past four years of the present Government regime. The report of the county medical officer of health states:

Due to emigration and migration to other parts of the country, the population of the county has fallen by over 20,000 persons between census years of 1926 and 1956.

He went on to say:

I believe that when the census is taken next year that it will reveal the population of the county has fallen well below 60,000 persons.

He further states:

There are no factories or industries giving employment to large numbers, the population being largely self-employed on small holdings and in consequence comparatively few are insured under the Social Welfare Acts. When the bread winners fall into ill-health they and their families have to depend on Home Assistance and/or an allowance under the Disabled Persons (Maintenance) Regulations, 1954.

He suggested that this letter be brought to the attention of the county council in the hope that they would approve of his suggestion to the Minister, namely, that the council

might consider requesting that the normal 50 per cent. Health Recoupment grant be increased in this county to, say, 60 per cent. and that home assistance be also made eligible for recoupment.

Is that not a shocking indictment of the present Government's policy for the past four or five years? When that statement came before the county council, the suggestion was adopted on the proposition of the chairman, Deputy Beirne, seconded by Councillor O'Rourke. We all remember who Councillor O'Rourke was. He was chairman of the Fianna Fáil Party in this House. As one of the keymen of the Fianna Fáil Party in Roscommon, he seconded the request to the Minister for Health to carry out these suggestions. Therefore, the Minister cannot suggest to me that this is an anti-Government motion and that I am trying to make political capital out of it. The position is so serious that a very respected member of his own Party seconded the motion in the hope that, by doing so, the Minister would be persuaded to do something to ease the situation in Roscommon.

I do not know what function the Minister has in regard to the improvement or reconstruction of county homes but on a number of occasions I have visited the county homes in Roscommon and I have always come away feeling completely depressed by the conditions obtaining there. I do not suggest for a moment that the people who run them, the nurses and nuns, are in any way to blame for the conditions. The conditions have been brought about by the state the buildings are in and the lack of amenities and facilities. It is a dreadful thing that old people are put in there by their relatives in conditions which anybody with any feeling would agree were absolutely unchristian. I do not know whether the fault lies with the local authority or with the Department. I wonder is it a question of the Minister telling us that he had no funds.

Mr. MacEntee

I have told them that I have funds. I told them that last year.

Mr. McQuillan

If the Minister explains the position, I would appreciate it, so that we will know where we stand. Does the Minister tell me that he has informed the local authority in Roscommon that sufficient funds have been available all along for the necessary reconstruction and improvement of the county home——

Mr. MacEntee

I did not say "all along". I said that last year there were, not this year.

Mr. McQuillan

It would appear from the Minister's comment that if there has been a delay over the past 12 months, it cannot be laid at the door of his Department. I wonder at whose door can it be laid?

Mr. MacEntee

It is due to the difficulty of preparing plans for the renovation and reconstruction of these old buildings. That is where the delay is. It is a planning delay and I do not think the local authority is responsible for it.

Mr. McQuillan

Whoever is responsible, it should not be allowed to continue. When we do not visit these institutions, we are apt to forget what conditions are like in them. It is only when we visit them that the tragic situation is brought home forcibly to us. People in Departments and high positions should visit such institutions regularly—I do not like to have to use the word "institution"—to see for themselves the conditions under which old people are expected to live. If that is done regularly, it will bring home forcibly the human aspect and the misery which is enforced on these people, because when we live in ivory towers and in Departments, we are apt to look on the human being as merely a cipher.

I am glad that there is one hopeful prospect in the Minister's speech, that is, that the present Health Act will be got rid of and a proper and sensible health service brought in, even though it is going to come as a result of the Minister having been pushed and dragged even perhaps by his own backbenchers who, as Deputy Dr. Browne said, are far closer to the public mind, who, knowing their needs, are beginning to feel that things are not too good down the country and to decide that the demand, which has been going on for years, for a choice of doctors is one that will have to be met. As a result of pressure, the Minister has inserted a few sentences in his address to hold out hope that that will be afforded in the future. At any rate, there has been a break-through and we hope that there will be a break-through in other respects.

Mr. Coogan

I do not know whether the Minister meant it but in his opening statement he paid tribute to the inter-Party group, led by Fine Gael, in so far as he stated that the death rate from tuberculosis has reached a record low figure.

Mr. MacEntee

Yes, we got you out of office.

Mr. Coogan

It is refreshing to note that the Minister in his statement has swallowed his words in so far as it was not a waste of public money. That was the battle-cry the Minister and his Party had throughout the years, that the expenditure by the inter-Party Government to try to achieve a measure of control over tuberculosis was a waste of money. The target has not yet been reached but when the inter-Party Government took over, there was a continued decrease in tuberculosis. We thank the Minister for his recognition but of course he has come a long way since then. He has even worn a tall hat.

We should also thank the people who established the Hospitals Sweepstakes and who made it possible for the Minister to achieve a certain degree of success. The Minister and his Party were loud in their cries that it was a white elephant. I wish we had a few more such white elephants.

While great strides have been made in regard to hospitalisation, much is still to be desired. Like other Deputies, I should like to refer to the great need for treatment for physically and mentally handicapped children. We are fortunate in the great work the religious Orders have done in this regard but there is still a lot of ground to be covered. I understand that the Minister is awaiting the report of the Commission dealing with the problem of mentally handicapped children. I do not think he should await it because we have this group of low grade mentally handicapped children who are in need of immediate treatment. A bed unit to deal with 80 to 100 children would go a long way to alleviate the distress in that field.

The Minister said he does not know what it is intended to do with Woodlands Sanatorium in Galway. Possibly if the Minister gave an increased capitation grant, we might get some Order to take over this hospital, which has been closed down for a number of years, and use it as a unit for mentally handicapped children. That is the background to it. The Minister can correct me if I am wrong but I believe that is the reason we cannot get somebody to take it over. It has been stated in the Minister's report that it is intended to provide 300 beds within three years for mentally handicapped children. Must we wait for three years or will something be done in the interim period?

Mr. MacEntee

I made it quite clear that so far as buildings are concerned we are going ahead as quickly as we can.

Mr. Coogan

I am glad to hear that. I hope the Minister will give immediate attention to the low grade mentally handicapped group who are a worry to their people when kept at home. They should get priority. I have come across some very pathetic cases and I can only describe them as a blot on our system of hospitalisation.

Some time ago the Minister had doctors removed from the dispensary districts in West Galway. I do not intend to go into the pros and cons of that but I wonder what steps the Minister has taken since to see that there is a proper dispensary service in these areas. These areas are now attended by the doctors from other dispensaries. It is deplorable that people must go so far afield to get a doctor when it might make all the difference between life and death. It would be incumbent on certain public representatives who took a great interest in having these doctors removed to see there are doctors there to replace them. Something should be done in that connection in the near future.

Another matter that is causing grave concern is the ministerial order— because it is a ministerial order—in regard to the discharge of patients from the regional hospital in Galway. Hardly a week goes by without complaints from people who have had some member of the family discharged in an unfit condition, unfit in the sense that though they cannot be treated further, their own people cannot look after them. There are cases of cerebral stroke and things like that. It is very wrong that such people should be discharged. It means that sometimes a mother has to look after a large young family and a very ill father. I know there is a ministerial order to that effect. In fact the Minister sends down his medical officer now and then to see that it is enforced. I would advise this medical officer to go a step further.

Mr. MacEntee

The county hospital is not a county home. It is a hospital for acute cases. The complaint used to be that the hospital was being overcrowded and acute cases could not be admitted.

Mr. Coogan

I quite agree but I will come to that point. Would the Minister like to go into a county home if he could not afford——

Mr. MacEntee

If I were an acute surgery case, I should not like to have to stay at home because I could not get into a hospital.

Mr. Coogan

With all the millions of pounds that have been spent on hospitalisation it is about time we were able to treat people until they are cured or beyond aid. If that is the Minister's solution, to tell the people to go to the county home, the people may tell him where he can go at the next election. Another burning question is the provision of teeth and spectacles. Some people are going around, as we say, mantach for about two or three years, having got their teeth out and having no hope of getting dentures from the local authority. Of course the Minister and his Party stood up at every crossroads and promised the people everything from wigs down to wooden legs. The first step is the provision of teeth and we cannot even get a tooth for the people. The same applies to spectacles. Would the Minister indicate what can be done in this respect or must a person go to court to demand his rights?

In the last few lines of the Minister's long-winded statement—27 pages —only four and a half lines are devoted to the nursing staffs: "Proposals for increased remuneration are at present under consideration following the submission of claims for all grades of nursing personnel employed in the local service." It is about time these nurses got better treatment. Without their services there would be no hospitals. Is the Minister not taking advantage of the fact that nursing is a vocation? He is leaving nurses to continue on in the hope that they may get something. He has no consideration whatever for them. He wants to convey the impression that we cannot afford any increase to the nurses. The Government can afford the cost of some grandiose schemes while the nurses get the cold shoulder from the Minister. They have been treated very shabbily.

In regard to student nurses, the Minister wants to put them in a different category from the trained nurses. Surely the amount of work done by the student nurse in a hospital justifies an increase in salary. Our hospitals are staffed 85 per cent.—in fact I could go up to 90 per cent.—by student nurses. One wonders how long a hospital could carry on without their assistance during the long hours they put in. Although nurses as a whole have a grave responsibility and work anything up to 11 hours a day they are treated in many cases with contempt and paid less than any clerk or Government official with little or no responsibility. Nurses have responsibility for life and death and it is about time the Minister considered their case. There is bad blood between the Minister and the Irish Medical Association and he should not put himself in the same position with the nursing profession. In regard to the prevention of disease, I often wonder what steps have been taken by the health authorities to check up on cinemas and dance-halls.

Mr. MacEntee

We have no jurisdiction.

Mr. Coogan

If the Minister bears with me, he will find he has.

Mr. MacEntee

I have not, you see, under the law.

Mr. Coogan

In regard to the ventilation of dance-halls——

An Leas-Cheann Comhairle

That would be a matter for another Department. It does not arise on the Estimate for Health.

Mr. MacEntee

Local Government is your mark there.

Mr. Coogan

I should like to know if the Minister has any say in the disinfecting or disinfestation of these cinemas. Is it Local Government or the county medical officer that is responsible?

Mr. MacEntee

We are responsible for disinfestation.

Mr. Coogan

How much has been done by the Minister's Department? This is something which helps to prevent disease and protect future generations. I hope the Minister will at least consider an increase for the nurses because they are well worthy of anything they get.

Mr. MacEntee

I just wish, so that Deputy Coogan may not be under any misapprehension, to say we are responsible for disinfestation but we are not responsible for the disinfecting. I am sure the Deputy will see the point.

I think I had better begin by dealing with a number of details of administration rather than the questions relating to general policy which have been put before me. In that regard, I had better begin with Deputy Russell rather than my predecessor, Deputy T. F. O'Higgins, because I might be able to make a rather more, shall we say, cohesive reply dealing with the remarks made by Deputy Russell and by the Leader of the Opposition. Deputy Russell is naturally very interested, as I know, in the problems of cancer prevention and therapy. I would hope that, perhaps, we might be able to associate ourselves with the reorganised Cancer Association in due course.

I am sure Deputy Russell will be glad to learn that as far as cancer research is concerned, we are limited not so much by our financial circumstances, although they are of course a handicap, as by the fact that the number of research workers available to us is limited. St. Luke's Hospital affords its professional staffs every reasonable facility for keeping abreast of developments in other countries and for research in the hospital. During the present year, an assistant medical director has been awarded a World Health Organisation fellowship for the purpose of studying current developments in radiotherapy in a European country, probably a Scandinavian country. A senior physicist is at present engaged on a six weeks' study of radioisotope work in Sweden. The technical and professional staffs visit British institutions as required to avail themselves of the experience of their opposite numbers in those institutions in connection with any projected developments at St. Luke's.

Research facilities have been provided at St. Luke's for an investigation into fibrinolytic activity of sulphony-lureas in patients with malignant disease. The House must bear with me. These words are not familiar and do not come tripping off the tongue; but they will be properly reported, I hope. This work, which is being done under the direction of Professor O'Meara and Dr. Barry, is related to the possibility of inhibiting the development of malignant tumours by chemotherapy, and, according to the statement recently released to the press by Professor O'Meara, it shows promise; but it is still at a research and not a treatment stage. Trials of other chemotherapy procedures on lines being followed elsewhere are constantly made, and any equipment or materials required by the professional staffs for this purpose have been made available by the hospital.

In addition to the facilities provided at St. Luke's hospital, a grant during the present year will enable the Medical Research Council to promote research into cell metabolism, which has a considerable importance in relation to the study of malignant disease. The grant, which is at the rate of £6,500 a year and which will continue for five years, is additional to the ordinary grant of £40,000 a year made to the Council.

The cancer registry which was established in 1957 is still in operation at St. Luke's hospital. Hospital authorities and medical practitioners are frequently urged by the hospital to cooperate by notifying all cases of malignant disease which are diagnosed or treated, but up to the present the only substantial response has been by the cancer hospitals. The information collected is classified in a manner designed to facilitate its use for research of a statistical nature and is available to workers in that field.

Deputy Desmond does not believe in commissions of inquiry. I do. I do not think it is possible, with the huge burden of administration imposed upon the staff of any Government Department, to make the sort of comprehensive survey of a problem necessary before we embark upon a concentrated attempt to solve it. In relation particularly to these problems of mental handicap and mental illness, there has been such a deepening of knowledge and accumulation of experience of treatment over half a century, or perhaps a little longer, that if we are to spend, as we shall have to spend, very considerable sums of money, having regard to our economic resources, it is essential that we should satisfy ourselves we are proceeding upon the right lines.

It is essential also that we should have this survey made in order that our own people may become familiar with the developments taking place the world over in the course of discussing them with colleagues from other countries and with a number of people who may be said to have a specialised knowledge of the narrower aspects of the problem. In that way, I think, by an exchange of views, by a study of memoranda submitted to them, especially as a result of hearing evidence, we can feel reasonably certain that the recommendations which will emerge from committees and commissions of this kind—the one I have set up and the one which I hope to establish in the course of the next two or three weeks—will be readily acceptable as authoritative and as reliable.

The Deputy also referred to the question of the accommodation for staff in mental hospitals and suggested that the accommodation should be improved. We all recognise that and we have set about urging and encouraging mental hospital authorities to improve conditions both for the staff and the patients. I do not think the question in relation to conditions, wages, time and so on, will come before the Commission except in a rather secondary way, as indicating perhaps the things which must be done in order to attract the right type of officer into the mental health service.

So far as existing conditions and remuneration are concerned, these must be discussed, of course, with the representatives of the employers and the staffs. These representatives are the county managers who act for their respective local authorities in this matter. Certainly these things cannot be discussed with me or dealt with by me for the very good reason that any officer or employee in the health service of a local authority has a right to appeal to the Minister for Health if he feels aggrieved in relation to his salary or conditions of employment. If these salaries, remuneration and other conditions of employment are to be settled in the first instance by the Minister for Health there does not appear to me to be very much good appealing to the Minister for Health later in his appellant capacity. It would be like going from Dr. Jekyll to Mr. Hyde.

The Deputy also urged that school medical inspections should be improved. He said it is not enough that children should be examined only three times during their school life. We should like to improve the school medical services. We should like to have more frequent inspections. There are, of course, two considerations. Despite Deputy Dr. Browne's contempt for the little matter of pounds, shillings and pence—I have a very considerable respect for that little formula—if we have not got these despised moneys, it will not be possible for us to do anything, not even to sit in this House, not even to have to sit here and listen to Deputy Dr. Browne. That is one consideration.

The other consideration is the fact that medical officers do not grow on trees and those who would have to start these school medical services are in relatively short supply. We are in the situation that we cannot do everything all at once. We have, first of all, to ensure that we are able to remunerate these doctors, nurses and others, who engage in these school medical services and we have then to secure the requisite personnel as soon as we have satisfied ourselves that we can pay them.

Deputy Corry—I am sorry I was not here to hear him and I am speaking from notes which were made of his speech, but I can imagine the line it took—denounced root and branch the Department of Health. He may have, because he is sometimes kind to me, kept off the Minister. He certainly denounced everybody else who had anything to do with spending any money that was not spent in Cork. I appreciate that he is a very good advocate for the constituency which he represents and for the county in the public life of which he plays such a leading part. I notice that he has stated that he secured a guarantee of £2,000,000 in 1949 from the then Minister for Health, Deputy Dr. Browne, to proceed immediately with the building of a new Cork Regional Hospital.

First of all, I am bound to express, having regard to the circumstances of the time, some scepticism as to whether or not Deputy Corry did in fact get that guarantee, but that is what he said. Here was a new Cork Regional Hospital, a hospital which, I understand Deputy Corry now wishes to be abandoned and not proceeded with. If that is so, it is good news to the other people who can use that £2,000,000. It makes our position a little bit easier.

I do not wish to give the House the impression that the decision not to proceed with the new regional hospital for Cork can be taken lightly. It is true a great deal of money has been spent in Cork recently, and over the years, in improving existing institutions. Despite all the money spent on St. Finbarr's I am afraid its longevity is apparent on its face. It is not the most modern of hospitals in its layout and its general amenities. It has been improved very considerably and the improvements are a great credit to those associated with it. I should think it is the first Cork Board of Public Assistance, in whose particular charge it was, to be transferred to the unified health authority, but we have got to face up to the fact that there have been very great developments in medicine and surgery.

There is a desire on the part of the authorities of University College, Cork, to build up and develop their new medical school. Just as we have had to decide here in Dublin in connection with University College, Dublin, that a modern hospital would have to be provided in order to serve the needs of the Dublin Medical School, one consideration we will have to weigh very carefully is whether, having regard to the requirements, it would not be better to proceed with the erection of a new modern hospital in Cork. But that is not a decision that can be taken lightly any more than the decision to abandon the original project can be taken lightly.

I prefer to wait until the new Health Authority has been properly established, is working smoothly and has had an opportunity to review its needs in relation to all the existing accommodation, before I could come to a decision on the matter. It is not because I am dithering, as Deputy Dr. Browne said; it is just because I have seen so many mistakes, not the least of them made by Deputy Dr. Browne, that I think it is better that we should do nothing about this until we have a reasonably stable foundation on which to develop.

Deputy Desmond also referred to the question of the dental and aural services. Deputy O'Higgins referred to them also, and so did Deputy Dr. Browne, and asked what we were doing in relation to these services. I think Deputy O'Higgins is under a misapprehension, or at least his recollection was at fault in referring to the debate which took place here in 1952 on the Health Bill, 1952. I just want to say that the then Minister for Health, my colleague Deputy Dr. Ryan, was very explicit in what he said in relation to the dental and aural services which would be provided under that Act. He certainly went no way as far as Deputy O'Higgins suggested he had gone. He was rather careful to stress that it would be, in fact, an adaptation of the services which were provided under the Public Assistance Acts rather than the development of an absolutely wide-ranging dental and aural service such as the Deputy appeared to suggest.

Mr. T.F. O'Higgins

I was only quoting the section.

Mr. MacEntee

I had better quote what the Minister responsible for the section said about it. Speaking on the Second Stage of the Health Bill, 1952 —the reference is Volume 136, Column 1895—the Minister for Health, Dr. Ryan said:

A further large part —that is, of the Bill—

is concerned with the re-enactment, in modified form, of certain provisions of the Public Assistance Act, 1939. The only new principle involved is the handing over of the administration of certain provisions of that Act from the public assistance authority to the health authority.

At column 1896, he said:

Persons in the lower income group will be entitled to general practitioner medical care in local authority dispensaries or in their own houses, exactly as at present except that it is proposed to simplify the arrangements by which they will prove their entitlement to the service.

So, there is not, I think, any strong foundation for the belief that what was proposed was a comprehensive dental and rural service for everybody.

Mr. T.F. O'Higgins

That is what is in the Section—Section 21.

Mr. MacEntee

Yes, but subject to regulations.

Mr. T.F. O'Higgins

Yes.

Mr. MacEntee

In that connection I am proposing to regulate the existing provisions for the supply of dental and aural appliances. Under it, admittedly, appliances will be supplied to persons to the extent to which such appliances can be made available by the expenditure in any local financial year of such sum as may be determined by the Minister after consultation with the health authority. That will enable us, I hope, that is as personnel become available, to extend the amount, so to speak, of coverage of these services year by year.

In making available the service under Section 14, within these conditions, a health authority shall have particular regard to the needs of expectant and nursing mothers and persons certified by a registered medical practitioner to be suffering from tuberculosis. The most important part of the regulation, however, is not the specification of the classes which are to get the priorities but this one, that a health authority may, in lieu of making a dental appliance available, under Section 14 of the Act, in the manner prescribed by Article 8 of the General Medical Services Regulations, 1954, make, in accordance with an arrangement approved by the Minister, payment towards the amount of any contribution made or to be made by an eligible person to obtain a dental appliance under any other service or scheme. This relates to the provision of dental appliances under the Social Welfare Acts and, as you know, dentures are supplied at moderate charges, whether upper, lower or complete sets. If a person is not able to find the whole of that charge, the local authority may come to his assistance and provide a certain subvention to assist him.

We are endeavouring now to set up also a new system for the supply of aural aids. The difficulty there is that these appliances are very expensive and very delicate and, therefore, can easily get out of order. The persons who use them have to be educated into their use. We are now at the stage at which we are hoping to be able to arrange for a supply of these appliances economically and at the same time to build up a service to look after them. We are taking steps to train and organise members of these services which we hope will be economic and efficient and afford guarantees that the maximum possible benefit will be secured from them.

Until the scheme is fully functioning, it is proposed again to limit the supply of these services by a regulation which is set out in Part VI:

Aural appliances shall be made available by a health authority to the extent to which such appliances can be made available by the expenditure in any local financial year of such sum as may be determined by the Minister after consultation with the health authority.

It is the same sort of device as it is proposed to apply in the case of dental appliances and it is designed to secure and ensure that there will be reasonable and orderly development of the service. The regulation will also provide that, in providing aural appliances, a health authority shall have particular regard to the needs of children, persons accustomed to the use of aural appliances or persons having peculiar difficulties, persons dependent on aural appliances to earn a livelihood, mothers with the care of young children and persons who are both blind and deaf.

So that it is not true to say that we have failed to give any consideration to this problem. It is not an easy one but we have given more consideration, perhaps, to the question of the development of the dental services than to many other matters which are also clamouring for consideration. We cannot do everything at once. I have undertaken to contribute as Minister for Health, out of funds in my disposal, to the erection of a new dental hospital in the city of Dublin. The Minister for Education, on his side, is contributing an even more substantial sum.

Deputy O'Higgins referred to the fact that these are services that could be provided only by dentists and one of the great obstacles to be overcome in attempting development is that there has been, and is, a marked shortage of dentists not only in this country, not only in Britain but also in the Scandinavian countries where services are very highly developed indeed. It is not, as Deputy Dr. Browne suggested, a question of offering more money; the British and the Americans are able to offer very much more money than we and yet, wealthy and all as they are, the requirements of the dental profession are not forthcoming. I repeat, it is not a question of money but a question that this is a profession that requires arduous training, a profession that imposes arduous duties on those who embark on it and it is only in the last 10 or 15 years that it is seen to offer prospects that are more attractive than some similar avocations might offer. We are, like every other country, trying to make up leeway but we cannot go any further than there are dentists to man the service.

Deputy Esmonde referred to the question of the position of the Wicklow hospital and expressed surprise that action in a matter of this kind was left to the local authorities to decide. It had to be left to the local authority for the very good reason that if this hospital were to be utilised at all, the local authority would have to pay at least half the cost of keeping it functioning in one way or another. It was put to them, and they have decided, that they have no use for it. They have pointed out that their existing institutions provide more accommodation than they are in a position to avail of and, in fact, they say, I think, that they have not used the reconstructed former fever hospital in the town of Wicklow. Newcastle Sanatorium is only partly occupied. The position of that sanatorium is such that it may be devoted to another use altogether. In those circumstances the local authority were fully justified in refusing to accept the additional burden of taking over and maintaining a building for which they have no use.

The question was raised about the limitation of £800 imposed upon a certain section of those who would be eligible for hospitalisation and specialist treatment under Section 15. That is not as simple as Deputies might think. Much was said about the fact that in 1958 I increased the limit of income under that section from £600 to £800. It is a fact that in certain cases—although this was not adverted to by anybody, I think—the income limit is £1,100.

We also heard something in this debate about my relations with the I.M.A. and, when Deputy Sherwin mentioned the matter, I said that he ought to take it up with the I.M.A.— with the doctors. Having considered the position in relation to the social insurance code, I raised the limit for insurability under that code to £800. There is provision in Section 15, which makes every insured person eligible for free hospitalisation. Naturally, I had to extend that benefit to all insured persons, even though their income might be £800, and in order that every section of the community would be treated equitably, I had to raise the limit to £800 for the other classes also. But, of course, that is one of the justifications that the I.M.A. have advanced for the attitude they have taken up to the present Minister for Health. They argue that I was not justified in doing that, that I was depriving certain members of the profession of their bread and butter——

Mr. Sherwin

Of their caviar, you mean.

Mr. MacEntee

The Deputy dines with them more frequently than I do. I do not know. It was argued that I was treating the medical profession unfairly and as I do not wish any further to exacerbate relations between those who control the I.M.A.—I am not referring now to the medical profession—and myself, I do not think it is practical politics at this stage to consider raising that £800.

Mr. Sherwin

Is the Minister afraid?

Mr. MacEntee

No, just prudent, cautious—put it that way. Deputy Healy, I think, referred to the need for improvement in the South Infirmary, Cork. We have proposals before us for the erection of a new block which is to include an X-ray Department, at a cost of £50,000. These were submitted in August, 1950. The scheme is at present under examination in the Department. The Hospitals Commission had been consulted about the matter and their reply, I think, is that it appears doubtful whether the proposals could be carried out for the sum indicated. The South Infirmary, Cork, has not been badly treated. It has got over £280,000 already from the Hospitals Trust Fund and, as the amount of funds available to me for allocation in each year is very limited, I am afraid I could not consider any scheme which would cost not only £63,000 but—I am advised—quite a substantial amount more.

Deputy Healy also referred—as did other Cork Deputies—to the erection of a regional hospital in Cork. I think I have already indicated my position in that regard.

With regard to the North Infirmary, proposals from that hospital are under consideration and a grant has been promised for a scheme which will include the provision of improved living quarters. Suggestions have been made as to how this can be achieved and the hospital authorities have agreed to hold a conference with officers of my Department. That will be arranged. We are awaiting a further approach from the hospital on the matter.

Construction of a new admission unit for Cork—to which Deputy Healy also referred—is well under way. An offer of an increase in the grant has been notified to the local authority. A grant of 40 per cent. is also available for an improved central heating system. The Deputy also referred to the need for improvements in the Mercy Hospital, Cork. Proposals were received in the Department for the provision of a modern theatre suite at an estimated cost of £90,000. The hospital authorities were informed towards the end of March that, while a grant for that amount could not be allocated, I would be prepared to make a grant of £25,000 for a modified scheme for the improvement of the theatre on the understanding that that would be the maximum and that no part of any excess, whether capital or interest, would be charged to the working expenses of the hospital. The hospital authorities have not yet indicated whether this will be accepted or not. I suggest it should be because there are many other applicants in the queue.

Deputy Dillon—and Deputy O'Higgins to some extent but not as immoderately as Deputy Dillon—suggested that a whole batch of building work was available in the Department when I took office, which could have been immediately proceeded with, if it had not been for the fact that I closed down on all building projects. Nothing could be further from the truth. Virtually all building, financed out of the Local Loans Fund had been brought to a standstill by the Minister for Finance in 1956, simply because money was not available to him and he could not make it available to the Minister for Health. The proceeds of the Grand National Sweepstake of 1957 had been hypothecated in advance to meet commitments which were maturing and the whole of the money was disbursed and out of my hands. In fact, money had been borrowed on foot of income expected to accrue from the sweepstake and was already paid out in the first week of the new financial year. So there is no foundation and no justification whatever for the suggestion made here to-day that I deliberately held up building schemes in order that I should be able to make an announcement such as I made in introducing this Estimate.

Here is the position so far as I can ascertain it. Restricted schemes were agreed to in principle by Deputy O'Higgins early in 1957 which involved the expenditure of nearly £5 million. Not all of those schemes were ready to be proceeded with and would not have been started for another two years. There was no question of easing up or of shutting down deliberately on the construction of the new St. Vincent's Hospital and the new Coombe Hospital, which would account for £3 million of that £5 million. The fact is, first of all, there were no funds available. It is very easy to draw up a programme. That looks well on paper and is quite a simple matter, but a programme is not of much use if you have not got the money to finance the schemes mooted. Secondly, none of these major works would have been proceeded with for over two years.

There is another consideration. Deputy Dillon was very eloquent about the thousands of people he suggested I had driven out of employment by shutting down that hospital construction programme. If those works had gone ahead—they could not have been proceeded with, but if it was possible to proceed with them at that time— the total employment given would probably have been not more than 1,000 men. It used to be calculated that it takes £1,000 to keep one man in full employment for one year and it may take more now. Even with an expenditure of £3,000,000, having regard to the formidable expense of the construction of a hospital, the amount of employment given would be comparatively small.

In the case of the Erinville Hospital, the position was that the working drawings were submitted by the architect in September, 1956. The consulting engineers submitted drawings in 1956. An examination was made of the position to decide whether or not the scheme should be allowed to be proceeded with and on 14th February, 1957, Deputy O'Higgins finally decided that the documents should be examined and cleared up but that the scheme should not be allowed to go for tender until 1958 or 1959. There was no question at any time that the scheme was to be proceeded with immediately and that I directed it should be held up.

The fact of the matter is that though this scheme was more advanced than the others we had not the money. As soon as the money was available and I was satisfied that if the work was started, we would be able to carry it through to completion, then I agreed that we should allow it to go ahead. In the case of St. Vincent's, the draft working drawings were ready in 1956. There was some considerable progress made in taking out the quantities but the major difficulty was the form of heating to be used and this was not finally decided until October, 1958. Again, until that had been done, the work of preparing the contract drawings could not be undertaken and there was no question whatever of St. Vincent's going ahead.

The same is true in the case of the Coombe. Planning had already reached the sketch planning stage in 1956 and when Deputy O'Higgins received a deputation at the end of that year, he agreed that planning might proceed but he gave no definite promise that the work could start when all planning was completed. We have the money now. I met the authorities of the Coombe Hospital early in 1960 and following a discussion with them, an agreement was reached whereby I was in a position to say: "Provided the hospital does not cost more than £700,000, you may proceed with the work." The planning for that hospital is now in hands.

Deputy McQuillan waxed very eloquent today about a case in County Roscommon. I have the greatest sympathy for the man concerned but the simple fact remains that it happened either out of anxiety for his poor wife or out of the idea which is so common, and which Deputy Dr. Browne and Deputy McQuillan have been so sedulously cultivating in the public mind, that you cannot be treated properly in a local authority hospital, unless you go into a private or a semi-private ward and become the private patient of the surgeon in attendance. We heard Deputy Kyne speaking out of the depths of his experience—not out of prejudice, but out of a certain predilection for one system as against another—describing the devoted attention which the patients receive in the public wards of the Ardkeen Hospital and the skill and care which is lavished upon them by the highly experienced medical staff there and their devoted nursing staff.

They get all of that free. If any of the patients get that free and are in a public ward and think for one reason or another that they would be better off in a semi-private ward, they do at their own election and responsibility. They cannot expect—it is unfair to lead them to believe—that they can get all these things. They get no better treatment. Let that be clear. They will not get that treatment free of charge in a private or a semi-private ward. If they elect to choose that type of accommodation and if they choose it of their own free will, then, of course, they will have to pay the piper.

Mr. Coogan

Not always. If a man is ill, he does not care where he goes.

Mr. MacEntee

That is very often argued as an excuse. After all, cases such as Deputy McQuillan referred to today are the very rarest exceptions— at least, in my experience. He was able after four years to name only one. He made a great deal out of it. It was not suggested in this particular case that the unfortunate woman did not know where she was going. What has emerged is that it was by her own choice or the choice of her husband that she went to the semi-private ward. I am sure he did not understand the obligations he was accepting. It is not fair—and nobody was more aware of that than Deputy McQuillan—to blacken the health service as a whole, to blacken the institution concerned in this case, the obstetrician or gynaecologist dealing with it just because some person elected to take accommodation with all its responsibility for which he was not in a position to pay.

I also wish to point this out. As far as my information goes, this is a particularly unusual case in which there were many transfusions involving quite an abnormal quantity of blood and plasma which, of course, itself is responsible for almost 80 per cent of the bill. I am not quite sure —that is a rough calculation. Yes, indeed, that is so. The total bill was £77 and the cost of the transfusions was £63. That of course, was responsible, as I have said, for the amount of the bill.

Bad and all as the health services were, the local authority in this case is footing half the bill. It is providing £38 of it. After all, that is not a bad contribution by the ratepayers of the county Roscommon to meet this particularly hard case, if you like.

I also want to say this. This is the first case of this kind that has come to my knowledge in which the number of transfusions which had to be given in this semi-private treatment of a patient was very large. I am proposing to have the question of the blood supply and plasma necessary for these transfusions examined to see whether I cannot secure some reduction in the burden which falls upon people in those circumstances.

Deputy O'Higgins also referred to the growth of the district nursing service. About 100 new posts as public health nurses have been created by the Health authority since 1956. The original target was a nurse in each dispensary district, that is, about 600 nurses appointed gradually over a period of years. We have reached the half-way stage with 300 nurses and we are reviewing the service in the light of experience. Special training for public health and district nurses has been initiated by An Bord Altranais.

Progress reported, Committee to sit again.

The Dáil adjourned at 5 p.m. until 3 p.m. Tuesday, 20th June, 1961.