That is all the Minister can do. I hope the oral vaccine is as safe as MRC tell us it is because one of the difficult things for parents is the tremendous number of injections the unfortunate child is asked to have. If we could reduce the number for such things as mumps, measles, diphtheria and smallpox, the better it would be for everyone.
Of the cases that occurred of children who died from poliomyelitis, to what extent were these cases vaccinated? Were there any cases among people who had the full course or part of the course, and would the Minister tell us whether any of the people who died had the full course? Could I also ask the Minister if he is in a position to say yet in what way he hopes to carry out this general scheme of anti-polio vaccination? Is it to be on the lines of the existing scheme, free to certain groups, or is there to be a scheme free to all sections?
In regard to mental illness, the problem is, as the Minister quite rightly says, a vast one. It is a great thing that he is taking such an interest in it. The extraordinary situation over the years, in all countries and not just here, is the indifference with which this reality in every society has been treated by every section of the community. The public have been terrified by mental illness and people who ought to know better, the medical profession, have been relatively indifferent to mental illness.
When I went through medicine, I think we had half a dozen optional lectures and a very short course. Certainly it was a very limited course in mental illness, and as a result I honestly admit I knew little more than the average layman. I think that is a shocking thing. It is wrong that Dublin University, for instance, have no course in mental diseases, that the courses which are being initiated are relatively new. It is a tribute to University College that they have established a course in mental illness and try to create an interest in it and, at the same time, endeavour to build up the personnel needed to encourage young medical people to go into mental diseases, to upgrade the status of mental diseases in the curriculum.
Certainly, in my time, the most neglected aspects of medical training were mental illness and, I suppose, tuberculosis. The Minister has made a significant contribution, a significant advance in relation to legislation on mental diseases. As far as legislation is concerned, it is the obverse of what happens in general medicine. In the general medical services, we have the hospitals, the nurses, the doctors and the equipment but not the legislation: in the mental disease field the hospitals and the staffs are very short but the legislation is good. At least, we have an important part of the armament needed in order to deal with this frightfully complicated problem.
There was a time when I have no doubt I would have been happy to dogmatise on what the Minister should do in relation to mental illnesses but now that I realise I have a very limited practical knowledge, I am not at all sure. In fact, all I know is that it is a frightfully complicated business and I think the Minister is making progress to deal with it and that I should not tell him how to carry on. When he said "next year", I hope he meant this year in relation to when the Commission is likely to propose what is the right line he should follow in his approach to mental disease. There is a wonderful change taking place in chemo-therapeutic methods of all kinds. They have been greatly improved but there is very much more that can be done for the mentally ill than was done in the past.
This, in turn, has repercussions in that the public are no longer frightened of the disease as they were in the past, no longer ashamed of the mentally ill. Being treated for mental illness has come almost to the level of getting an appendix out or of being treated for typhoid, though, of course, mental illness is less serious than typhoid. I agree with the legislation aimed at encouraging the idea of the voluntary patient. It is very much better than the compulsion in the past to have a development towards a person coming for treatment and, within reason, being able to get up and walk out as soon as he feels better.
This has done two things. In the first place, it has opened the doors of the mental hospitals which had been shut like prisons in the past. Secondly, it is becoming more and more necessary that the standard of treatment— not only the medical treatment but the physical care of the patients in the institution—shall be very good. The quality of the food served, the quality of the nursing, the quality of accommodation—all must be good. Clearly, it is like the case of a bad hotel, the patient will go once but will not go back the second time. This business of letting a person go to see what treatment in a mental hospital is like has a dual function. If the medical and nursing staff are satisfactory and if the general conditions are good, the patient will return if he has a relapse.
If the Minister is to produce, as he has done, this kind of progressive legislation, he must very urgently do something about the general quality of the building as well as increasing the personnel. The difficulty, of course, at the moment is that the staffs are terribly overworked and simply cannot give as much care to the patients as they would like. The ratio of doctors to patient is still far too high.
The serious point to be dealt with —and we will have to wait for the Commission on this—is whether the Minister will need as many hospitals as he thinks he will need. There is a general feeling to try to keep these people out of hospital if at all possible. First of all, empty the mental hospitals of the old senile dementeds put in there in the past—people not really insane, who could be more properly looked after in the county homes or the good type of old people's institution. Then try to see how many of these people could be treated as outpatients. That would save the Minister a tremendous amount of money. Instead of embarking on a very expensive hospital building and reconstruction programme, he might find that what he really needs is a wide extension of the clinic facilities he has already provided for in his legislation and which have developed to some extent over the past ten years in various areas.
This is a good development. The general feeling among psychiatrists and such people has been to keep them out of hospital, if possible, and to try to get them at the clinics as outpatients. That has obvious advantages. The cost of running a hospital is one thing; leaving the person with his family is another. This question of mixing them in with the general hospital patient gives them the feeling that they are just another ill patient, not an exceptional patient, and that there is no odium attached to being mentally ill.
What the Minister is up against is the provision of considerably extended clinic facilities. Prima facie it appears to me there is a great need for more accommodation. But I do not know whether a survey would show that that problem is quite as serious as we think. I sympathise with the Minister in his reference to the county homes. Whoever built them appears to have built the mental hospital and the prisons, because there is very little difference between the three. I do not know how we could do anything about them with their cut stone granite walls about five feet thick. If I had my way, I think I should use a bulldozer on them. I do not know how the Minister is going to make inexpensively any useful changes in the mental hospitals. Because of the appallingly tiny windows and their massive granite structure, I do not think they will ever look anything else except what they were intended to be—prisons of a kind.
This is a problem which has so many facets to it that it requires the advice of a competent commission. We shall all look forward to the advice of that commission. As far as I can see, the problem is not really one of hospitals. It must be dealt with before these people get to the hospitals. The real problems are the stresses that create these mentally ill persons, and these are social and domestic problems. There is the problem of what to do with them when they leave hospital in order to prevent relapses. If they go back to the conditions which created the initial illness, the Minister will have them back in hospital in a relatively short time.
The Minister's problem is not in the remotest way a building problem. It is a very much bigger problem. I believe it is the biggest social problem anybody could be confronted with. If the Minister is to attack this problem seriously and deal with the post-hospital care of these people, the number of social workers needs to be multiplied by dozens in order to help keep these people out of hospital. That means we must stop people going into hospital and prevent them coming back. It is there the greatest expenditure will be. Occupational therapy may be a very valuable occupation—I do not know—but I think training for alternative trades would probably be wiser than simply making them something which sometimes takes a long time to make and is of very little intrinsic value when you have made it.
On the whole, this question of the rehabilitation of the disabled person is again a very serious problem. Where one has 60,000 unemployed people, healthy, able-bodied people, obviously you will not get employers looking forward to employing a one-armed man, a blind man, a person mentally slightly unstaple or liable to get epileptic fits. You will have difficulties so far as the trade union movement are concerned. They have this responsibility to find work for their able-bodied people. How you are going to have a rehabilitation service that really works, I do not know, unless you have a society in which there is full employment. That, again, is a social problem.
There is one small point which I wonder if the Minister would look into. A temporary civil servant, who might be asked to have mental or psychiatric care, has only a limited period of leave for ill health. There are probably administrative reasons for it, but it is not a good thing. The Minister can take it that, medically, it is a bad thing that a doctor should be faced with a patient who tells him: "I do not know if I can come again because I have exhausted my ill-health leave period." It is not a simple problem, and I cannot offer a simple remedy. The Minister might consider treating temporary civil servants on the very generous basis which, to my knowledge, the permanent civil servant is treated in regard to ill health. He may be treated in that way at present, but I understand he is not. From the doctor's point of view it is an undesirable dilemma to have the patient telling him: "I must get back to work because my ill-health period has expired." Even if the person could be allowed to get whatever treatment he needed and not be paid but have his job kept open for him, it would be of tremendous help to the patient in any illness, and particularly in mental illness where depression has become an important factor in causing the illness.
The problem of the mentally handicapped child is the saddest problem. Prima facie the Minister's problem appears to be beds. I think his marginal increase from 2,741 to 2,897 is no achievement if he is really interested in making progress. If he really wants to provide beds for these children, he should make much more energetic efforts. The difficulty again is that there is a difference of opinion, apparently, on medical grounds as to whether mental deficients should be treated at home or go to a clinic; whether the better thing is to increase the number of clinics. If that is the answer—I do not pretend to know—it is a saving for the Minister. Listening to people talking about this, they give one the impression that above all it is important that the person, whether child or adult, should be kept in the home environment and allowed to go once, twice or three times a week to a clinic, which would be staffed by doctors and nurses, psychiatric workers and so on. That is a healthier way of approaching the problem than locking these children in institutions.
I do not know what the answer is but it would be a great help, from the Minister's point of view, if it were found that to increase the number of clinics in the community answered the problem to a very considerable extent because that would reduce very much the number of beds the Minister might have to provide. The great tragedy with children who are mentally deficient—and they can vary from one or two or three grades—is that the parent has to face the inevitability of the time when he or she will no longer be there. What happens to the child? Must it go to an institution? I hope the Commission which is considering this whole problem will provide a solution as soon as possible.
I do not know to what extent we may talk about the general pattern of our health services. Naturally, it seems to me that in order to get maximum efficiency, one must provide the prerequisites of a health service, the doctors, nurses, hospitals, clinics, dispensaries and so on, as well as legislation. It is the legislation we lack at the moment. Since there is a Dáil Committee sitting on this whole question, I suppose we could leave aside the general principle under which the services should be organised for the time being. My views are so well known that I suppose I do not have to reiterate them —that the 1947 Health Act was the best piece of legislation that we have ever put through this House and that the best thing in it was the mother and child scheme. I hope the Minister will re-introduce it in the future. He would certainly have all my support. Is there any hope of putting it through the House, I wonder?
This may invade the sphere of the Minister's responsibilities but I wonder would he even briefly think about it. He speaks of the difficulty of getting general voluntary hospitals to share facilities but is there anything he can do about the present medical curriculum in the universities? May he even suggest—I know he cannot interfere—to those who care for our medical curriculum in the medical schools that they should take a second hard look at the medical training for doctors in the universities. To me it seems the present position is absolutely invidious from the point of view of the unfortunate youngster who wants to go through medicine. The course becomes longer and longer through having additions added at one end while nothing is taken away at the other.
I know the Minister's powers are very limited in this respect but could he go to the extent of suggesting to these people that they should consider the whole question of medical education and see to what extent they could reconsider the course as it is at present and do something about, say, the two years of anatomy. That, to me, seems crazy when there is such need for physiology and need to take account of other changes in chemo-therapeutic medicine and the advanced means of acquiring knowledge of chemistry, physics and other subjects which are relatively lightly treated compared with subjects like botany and zoology which I think are over-accentuated. I know the Minister is in a particularly delicate position in this matter but I think somebody should do something about it in the interests of medicine generally and of trying to streamline the course and get a more accomplished and efficient doctor at the end of it. One of the difficulties here has been the fact, as the Minister says, that the authorities of the voluntary general hospitals are reluctant to share facilities. There has been growing up a multiplicity of tiny hospitals doing reasonably good work but virtually ignoring the fact that specialisation has become absolutely essential, a specialist being a person who knows more and more about less and less. That is the old aphorism but at the same time specialisation is absolutely inevitable. Where one has a multiplicity of relatively small hospitals, you will have all the doctors carrying out practically every operation from removing an in-growing toe-nail to dealing with a brain tumour and that is bad for medicine and for the doctors themselves.
Where there is a very highly-skilled surgeon, he should be in a hospital where he will get as much of his type of specialised work as there is in the country. That is a general trend in other countries but is it taking place to any substantial extent in Ireland? The only serious specialisation I know of is in brain surgery, genito-urinary work and in relation to anaesthetics which have certainly progressed in recent years. I consider there has been no serious attempt to streamline the working of the hospitals but there is no reason why the volume of work which these men do should drop. It would merely mean that they would do more of their own particular speciality and do it better. It is like tying a bootlace: the more frequently you do it the better you become at it. The same applies to an intricate operation. In the case of a team of surgeons, no matter how technically skilled they may be I think it is wrong for them to carry out complicated operations very infrequently, wrong from the patients' point of view, because I believe the essence of efficiency in this case is team work, working together, and in that way becoming so good at the operation that a patient is at minimum risk. That is the only thing that matters.
In that regard, as a specific proposal to the Minister, is there anything he can do regarding the establishment of an accident service in our cities? One reads every weekend the appalling news of road crashes and one notes the increase in the number of cars on the road and the increase in accidents of one kind or another. We are not geared, so far as I know, in our hospitals to deal with this question of an emergency accident service.
I do not like asking the Minister to talk sense to a bag of cats—and I do not mean that disrespectfully to the people concerned—but there are tremendous vested interests concerned. The increase in motor accidents, which will continue, is very serious. We should have special centres staffed by people of the highest possible calibre. The general rule is to have the main accident centre where you have consultant opinion and then satellite centres which can carry out any major or minor operation and then smaller subsidiary centres where minor work is carried out.
The important thing about an accident is that a vital decision may have to be taken in a hurry. Sometimes terribly important decisions have to be taken on the spot which should not be left to anyone but the highest level consultant. The problem is how to get such a person to stay on duty from Friday to Sunday morning. Somehow, it should be done. It is wrong that a registrar or a house surgeon or a house physician should have to take one of these very serious decisions. With the best will in the world, he has not the training to do it.
Maybe the Minister might have the temerity to suggest to these consultants that they should do something about providing some form of really high-level accident service. In the public interest, some steps should be taken to establish some form of efficient accident service in the country. This, obviously, must be taken together with the organisation of an ambulance service.
I have heard complaints about the ambulance service. I do not know whether they are as bad as people say they are. On the whole, I never had any trouble with them. In view of the many appalling accidents now taking place, is the Minister satisfied that the type of ambulance service which he has, based on the average local health authority, is sufficient for the needs of a serious accident where a couple of people are badly knocked out? Are the people who man the ambulance competent for the work? Would the Minister consider that he should try to establish some kind of ambulance service, based on a regional service, staffed perhaps by lay nursing and medical personnel—I do not know— who would be able to do the right thing at the time of a bad accident case? You can kill somebody by doing the wrong thing. If you lift a person with a broken back you can give him paralysis of the lower limbs and there are very much more serious things than that.
I am delighted to see some progress being made in regard to the county homes. They were the worst things I was aware of in our general service. In fairness to the Department of Health, it should be said that, generally speaking, the hospital section of the county home was reasonably satisfactory. As far as I know, the Department had to pay a certain amount of the cost.
My recollection of Mountmellick, unless I am mistaken, is that it was the second worst. It had one bath with verdigris on the bottom and one cold water tap. Longford was the worst, with an open sewer running across the yard. I am glad to see that they are doing something in a number of places about the county homes. Longford is not mentioned. Has the work been completed there or is it that they have not decided to do anything yet about it?
A tremendous amount needs to be done in regard to the county homes. It seems to me to be the test of a civilised society how one treats the aged. Anybody who is in any way complacent about our society here should go to Sweden to see the places there where the old people live. They are the most lovely hotels, effectively, of the highest quality, attached to hospitals and old people are living there with dignity. They are very happy to go into these old people's homes. Their relations come to see them.
It is no good to say now that you should keep the old people in the home. The Minister is a great believer in that and so am I but there are occasions when they cannot have any real comfort or the peace or isolation that they want. It is an evasion of our responsibility if we do not speed up the provision of adequate accommodation for our old people. One of the things that shocked me was the dreadful attitude to the old people. Their clothes were dreadful but, leaving that aside, there is the point mentioned by Deputy Tully of breaking up the family—the wife going in one direction, the husband in another direction and sometimes the children in a third direction.
It is difficult to know, when dealing with all these problems, whether the provision of adequate accommodation for old people should not be the first responsibility of any community, because their life span is short. I do not know if the Minister has visited many of these places. Unless they have changed very much since my time, most of these places are desperately cheerless—an old barrack-type building with inadequate heating, undecorated, very sparse and very spartan bedrooms. The cooking facilities are often terrible. I remember the Longford home particularly, where there was a big boiler into which everything was poured. The unfortunate nuns who were trying to run the place were working under the most primitive conditions. Everybody here praises the various Orders who look after the county homes and say they are doing wonderful work. They are doing wonderful work but there is no reason why they should be crucified doing it. It is like the teachers in the schools. I do not see why the nuns should be asked to work under substandard conditions.
I know that the Minister seems to be making some progress in regard to the provision of more county homes and I know that he is restricted by the interest shown by the local authorities which sometimes is pathetically inadequate. Their interest in their responsibility to old people is sometimes pathetically limp. Again it comes to the question of who is to pay, a question of the rates and of all that. As far as I can see, that is the basis of the Minister's difficulties.
I do not know what the Minister is going to do about the recruitment of dentists and doctors. The attraction away from the country is tremendous. The British, who are drawing away our people by the salaries they pay, are at the moment deeply concerned about what they call their own "brain drain" so that it is very difficult to know what the solution to the problem is going to be.
While it is a good idea to get young people to go into our various services, it is equally good to encourage them to travel and then to come back. That is where the Minister must use his strongest incentives, to try to make it worthwhile for these people to come back into our services when they have been away for a while and have gleaned useful information which can be of advantage to our people when they find employment in our various hospitals and in the general health services.
