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Dáil Éireann debate -
Thursday, 20 Feb 1964

Vol. 207 No. 10

Committee on Finance. - Vote 52—Health.

I move:

That a supplementary sum not exceeding £10 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1964, 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.

Perhaps I should explain at this stage that there is another Supplementary Estimate tabled for my Department, for a sum of £485,000. I intend, with your permission, a Cheann Comhairle, to mention this proposed provision in the course of my statement, but this second Supplementary Estimate will not, of course, be moved until the end of the debate.

Has that Supplementary Estimate been ordered for today?

It is the second Estimate?

Yes. I shall begin by reviewing briefly the more significant vital statistics. In 1962 there were more births, more marriages and fewer deaths than in 1961. I am not claiming credit for all that, of course. The number of births registered was 61,782, an increase of 1,957 on the previous year. The rate, at 21.9 per 1,000 of the population, was again appreciably higher than in England and Wales where it was 18.0 per 1,000 and in Scotland where it was 20.1 per 1,000. The number of marriages in 1962 was 15,627, an increase of 298 on 1961. The number of deaths was 33,838, a decrease of 925.

Heart disease, accounting for 10,974 deaths as compared with 11,064 in 1961, was, as previously, by far the most fatal of morbid conditions. Next to heart disease, but a long way behind it, cancer was again the greatest "killer". It accounted for 4,897 deaths in 1962, as compared with 4,704 in the previous year. Of the deaths from cancer, 697 were from those forms of the disease which are grouped under the title of lung cancer. The corresponding figure for 1961 was 682. I shall revert to this matter and comment upon it later. When introducing the Estimate for 1962-63, I expressed the hope that a cobalt unit for cancer treatment would soon be available at St. Luke's Hospital, Rathgar. I am glad to be able to report that the installation of the necessary apparatus was completed during 1962 and that patients have been receiving treatment at the new unit since November of that year. Recently I sanctioned proposals for the provision of a second cobalt unit at St. Luke's and for a further unit at St. Agatha's at Cork. It will, however, be some time before these two new units are in operation. I may mention here that recently a research project into the manner in which cancer spreads in the human body from its site of origin has been embarked upon at St. Luke's Hospital. This study is not being financed from funds at my disposal, but important accommodation and facilities for it are being made available at the hospital.

Simultaneously with the erection and equipment of the cobalt unit at St. Luke's Hospital a new department for the provision of a radio-isotope service was also built and equipped. The capital and running costs are high and it is imperative that the services it offers should be availed of on a wide scale. This has been arranged for and the department at St. Luke's Hospital is providing services for other institutions and for large numbers of outpatients.

Before I pass on to the other matters which arise out of the Estimate, I feel that I should again recall how the recently-issued Report of the Advisory Committee to the Surgeon-General of the United States Public Health Service on smoking and health has highlighted the grave hazards which statistical studies indicate are associated with smoking and, more especially, cigarette smoking. I do not wish to labour the point but if I were addicted to cigarettes, which I am not, I should accept that report as a very grave warning and change my smoking habits accordingly.

The total number of deaths from all forms of tuberculosis was 426 in 1962 as against 420 in 1961. The figure for 1962 is the second lowest on record. The incidence of the disease continues to decline, the number of new and reactivated cases in 1962 being about 200 fewer than in the previous year; thus the number of beds needed for adult respiratory tuberculosis patients on the 31st March, 1963, was 1,648, as compared with 1,883 on the corresponding date in 1962, and approximately 6,000 nine years ago.

The position is satisfactory, so far as it does. Nevertheless, it continues to be most important that everybody should make full use of the facilities available for the prevention of tuberculosis. To encourage them to do so the National Mass-Radiography Association proposes to concentrate more and more on community surveys, in the course of which an intensive effort is made to secure that everybody in a selected area except young children will come forward for X-ray. While, in general, the response to these surveys has been gratifying, it is regrettable that in some areas it fell far short of what was expected.

The number of maternal deaths during 1962 was 27, giving a death rate of 0.44 per thousand live births as compared with 0.45 in 1961 and 1.32 in 1957. But the rate in 1962 for England and Wales was 0.36, for Scotland 0.40 and for Northern Ireland 0.30. It will be seen, therefore, that we have much ground to make up in this most important sector.

The infant mortality rate, that is, the deaths of infants under one year expressed as a proportion of every 1,000 live births, resumed its downward trend in 1962, being 29 as compared with 30 in 1961 and 35 in 1958. The corresponding rate for England and Wales was 22 in 1962, while that for Scotland was 27 and for Northern Ireland 27. It is worth noting that the Maternity and Infant Care Scheme was availed of, fully or partly, in respect of 68 per cent of the 59,825 births registered during 1961.

At the instance of my predecessor in office, the Medical Research Council of Ireland have engaged on a survey into the causes of perinatal mortality, that is, of foetal deaths, occurring after the 28th week of gestation, and of deaths occurring within seven days after birth. The field work on this survey has been completed, and arrangements are in train for processing the data under expert professional guidance.

Infant mortality in the city here is somewhat higher than in the rest of the country; and it has been suggested that the prevalence of congenital malformations may be associated with this fact. Accordingly, I made a special grant to the Medical Research Council, from the Hospitals Trust Fund, and side by side with the perinatal mortality survey an investigation into the incidence of such abnormalities in infants born in Dublin city is now in progress. In this inquiry, which is necessarily a long-term one, an attempt is being made to isolate the factors that interfere with normal intra-uterine development. The survey is proceeding, but I do not expect that anything will emerge from it for some time yet.

Over the years the incidence of and deaths from gastro-enteritis in children under two years have continued to be exceptionally high in Dublin city and have been the cause of much concern. The Medical Research Council have interested themselves in the phenomenon and I have made a grant from the Hospitals Trust Fund to finance an investigation which has been proposed.

Before leaving the subject of maternal and infant care, I should mention that, at my urgent request, the Medical Research Council undertook a special investigation to establish, so far as might be possible, the number of babies born in each health authority area with deformities which could reasonably be attributed to the use by expectant mothers of the drug thalidomide. The Council have completed the survey and their report is now being studied in my Department. In the meantime I have requested the National Organisation for Rehabilitation to consider what facilities are required to assist the children involved. Many of them will require artificial limbs and the Organisation has arrangements in train for the provision of this service at the National Limb Fitting Centre at Dún Laoghaire.

There has been an overall decline in the incidence of poliomyelitis: in 1962 59 cases occurred with four deaths. An examination of the cases reported shows that young people are the most susceptible to the disease.

When introducing last year's Estimate, I referred to the developments in oral vaccination against poliomyelitis in other countries. I sought the advice of the Medical Research Council on this matter, and it recommended that a prophylactic service using oral vaccine should be organised on a national basis. However, I thought it prudent, because of reports received in September, 1962, of cases of poliomyelitis in Canada and the United States following the administration of oral vaccine, to defer the introduction of the service here. The Medical Research Council have again considered the question in the light of investigations which were carried out in the countries immediately concerned, and have endorsed their earlier recommendation. I propose to proceed in accordance with this renewed recommendation and hope to introduce a general scheme of anti-polio vaccination during the coming financial year.

Last year I made special reference to the problem which had been presented by the outbreaks of smallpox which had occurred during 1962 in Great Britain and in the Federal Republic of Germany. Fortunately, no case of the disease was imported into this country but that the public were alive to the danger was demonstrated by the fact that during the first six months of 1962, over 300,000 people were vaccinated against the disease. Though this fact in itself was gratifying, it would be much better and more effective if vaccinations were accepted as a routine measure rather than as a safeguard to be sought en masse when an emergency has developed.

As some public anxiety was manifested when it became known that a case of typhoid had been imported into Dublin from Zermatt, I should make it clear that our public health service is organised and fully equipped to deal with occurrences like this, and that, when circumstances warrant them, all necessary steps to prevent the spread of infection are taken.

I turn now to a second group of diseases, those which disable rather than kill. Foremost among these is mental illness. Despite the fact that the number of mentally ill under institutional care was further reduced during 1962, the condition continues to be one of the most pressing problems in the field of health. The numbers under care increased steadily in the post-war years up to the year 1958, since when there has been a gradual decline. Notwithstanding that over the past five years there has been a reduction of 1,800 in the number of hospitalised mental patients, overcrowding continues to be one of the worst features of our mental health services.

Some of the reduction was secured by transferring to redundant sanatoria elderly patients, who no longer needed psychiatric care, but for the most part, it was achieved by more intensified treatment, leading to earlier discharge, for those admitted to hospital, coupled with the continued rapid development of out-patient services. On the other hand, the number of admissions to mental hospitals has also tended to rise, partly because of an increase in the rate of re-admissions, but mainly because the improvement in the services has created a greater demand for them. Patients are coming forward more readily for treatment and seeking it at an early stage in their illness, at which time the prospects of its success are greatest. The rising re-admission rate is by no means peculiar to this country, and is mainly attributable to the fact that it is now the accepted thing to give a patient his discharge when he has recovered sufficiently to permit this to be done. Formerly such a patient might be retained in hospital indefinitely.

More and more, it is becoming obvious that a high level of community services is an essential element in mental therapy; and I hope as trained personnel becomes available to provide these more generally than heretofore. On the other hand, while in-patient care remains a vital part of the psychiatric services, it is no longer generally regarded as the first line of defence; it is now viewed as a service of last resort, to be availed of only when the possibility of keeping the patient within the community and out of hospital has been exhausted.

Though we have still, I regret to say, substantial deficiencies to make good, conditions in our mental hospitals have improved considerably. It is, of course, mainly a matter of the large sums of money which are required to repair generations of neglect. Yet, I believe, I can claim that with the little we have had at our disposal much has been done. I have continued to stress to mental hospital authorities the need to upgrade their institutions. They have been on the whole most receptive to my suggestions, and I am glad to be able to say that as result, considerable improvement works have been completed or are in progress.

With my approval, a Training School for Occupational Therapists has been set up at the National Rehabilitation Centre in Dún Laoghaire. This centre now has 25 students. Next year the number will be increased by a further 30 and in the following year, there will be yet a further increase. Occupational therapists are not, of course, employed exclusively in mental hospitals, but the availability of personnel, adequately trained in occupational therapy, will considerably enhance the outlook for the mentally ill.

There is not anything so depressing as the spectacle of large numbers of patients sitting around in day-rooms and corridors of a mental hospital, doing nothing. As our capability to occupy the patients in more congenial tasks increases, the change for the better in the morale of patients will be accelerated; for nothing produces a more favourable therapeutic response in the mentally ill than to be made to feel that, however handicapped, one is of some use in the world. The pride and delight which mental patients exhibit in their occupational accomplishments is convincing evidence of the important part which useful and worthwhile employment can play in the cure and rehabilitation of the mentally ill. Therefore we shall do our utmost to develop and diversify our facilities for occupational therapy.

Deputies who participated in the discussions on the Health Authorities Act, 1960, will recall that one of the more teasing problems to be dealt with originated in the fact that for the purpose of the mental hospital service the county of Wicklow was conjoined with the city and county of Dublin in the Grangegorman Mental Hospital Board. Apart from the fact that some reconsideration of the organisation of the mental health services under the Dublin Health Authority would be opportune, I have taken the view that it would not only be advantageous to Wicklow to have its own mental hospital, but that if it had, the problem of overcrowding in St. Brendan's and St. Ita's hospitals might be a little eased.

Thanks to the public spirit of the authorities of the Royal National Hospital for Consumption for Ireland, Newcastle, County Wicklow, to whom I, with the people of County Wicklow and of Dublin city and county, am indebted, it became possible to suggest to the Wicklow County Council that they should establish their own mental hospital. The county council are considering the suggestion and matters are now, I hope, in train for establishing a new mental hospital in the premises of this former sanatorium.

Other very desirable projects in regard to the services for the treatment of mental illness made some progress during 1963 but it would be more appropriate to deal with these in connection with the Estimates for 1964/65.

The Commission of inquiry on Mental Illness which I asked to examine our existing mental health services, are still pursuing their task with care and diligence. At the beginning they were hampered by the inadequacy of the statistical information available. However, a new system of returns which was introduced on 1st April last will facilitate their researches and will assist us in planning hospital accommodation and psychiatric services for the future.

How true it is that mental illness is one of our most pressing health problems is borne out by the fact that we still have 19,250 of our people in mental hospitals. Among European countries we have an unenviable record in this regard. Why this should be so is not at all clear; but, whatever the reasons, the present position makes a considerable drain on our social and economic resources. But, as I have just set out, every effort is being made, on the basis of our present knowledge, to remedy the position by continuing to improve and expand our treatment services.

The House will recall that some years ago my officers made a preliminary special study of the problem of mental handicap on the basis of which I subsequently issued a White Paper entitled "The Problem of the Mentally Handicapped". That document indicated that among the major difficulties to be overcome—apart altogether from the provision of additional accommodation and the recruitment and training of staff-were the ascertainment of the number of mentally handicapped persons, the precise nature of the services and the accommodation required for them and the form of training best suited to our circumstances. With our limited resources, it is of paramount importance to obtain sound and well-considered answers to these problems.

With this in view, I set up a Commission of Inquiry to look into the whole position. The personnel of the Commission is expert and representative, and its terms of reference are very wide. It is, however, faced with a truly formidable task, for there has never before been a planned approach to the problem of mental handicap in this country. The Commission has been meeting regularly and I am hoping it will be able to submit its report within the next year, perhaps even within this year.

In the meantime we have been pressing forward with the provision of extra accommodation for mentally handicapped persons. Thus the number of beds available, which on 1st April, 1962 was 2,703, had risen by 31st March, 1963 to 2,741. In the nine months ending on 31st December last, it rose by a further 156 to 2,897.

Included in the figure for the increase in the last nine months mentioned are 40 places provided by the authorities of Peamount Sanatorium for adult mentally handicapped persons who had received training in one or other of the institutions provided for the training of boys. By accepting these patients, the Peamount authorities made possible the admission of 40 new children to intensive training institutions. This development is a very desirable one indeed. It will not detract in any way from the credit which is due to the organisations which have been longer in the field, if I publicly thank the Peamount authorities for their co-operation.

Further additions to the accommodation available for mentally handicapped patients are in course of planning but, as in the case of development in the mental hospitals, I think it more appropriate to deal with them when presenting next year's Estimate.

In recent years voluntary organisations in the cities and larger towns have established services in day-centres, schools and crèches for the mentally handicapped; and these are being availed of by a constantly increasing number of children. Naturally, I have followed with great interest these developments in community care. Apart from the immediate benefit accruing to the children attending them, the experience derived from them may be of assistance to the Commission of Inquiry in formulating its recommmendations. I am sure that every Deputy will join with me in expressing appreciation of the zeal and devotion of those who have been associated with them.

The Dáil is aware of the good work of voluntary organisations in the development of vocational rehabilitation services. Regulations which I made under section 50 of the Health Act, 1953, enable financial assistance to be given to these bodies. Other regulations also made by me empower health authorities to pay allowances, where necessary, in respect of trainees to cover maintenance during training. Facilities for training and services for the placement of disabled persons in employment are available through the Rehabilitation Institution Ltd., and the other voluntary organisations working in this field; but existing facilities in vocational schools are also to be availed of in suitable cases. It should be borne in mind that the regulations concerned with vocational training and placement in employment differ from those concerned with medical rehabilitation. Medical rehabilitation is a separate service and has been developed, under other provisions of the Health Acts, as a part of the hospital and specialist services.

In recent years great emphasis has been laid on the need for greater productivity and efficiency in industry. It has not been so generally realised that it is equally desirable to secure the maximum of efficiency in the health services. An unnecessary duplication in this field of accommodation, equipment, or personnel is an unjustifiable dissipation of resources. If resources become superfluous to a particular service, or if a service may be made more economical by efficient reorganisation and pruning, the superfluities can be readily used in the improvement and expansion of services — and there are several—not yet at their optimum. All those concerned with the services, whether individuals, health authorities or other bodies, must have constant regard to considerations of efficiency and economy. My obligation as Minister for Health is to ensure that in the allocation of public funds for capital purposes new accommodation or equipment is not provided except where the need cannot be met by existing institutions or by special arrangements for co-operation and the sharing of resources between them.

Considerations of economy and efficiency are particularly pertinent in the case of sanatoria which, because of the decline in tubercular disease, are under-utilised or are redundant. Some health authorities are reluctant to permit such places to be put to proper use and will only do so under extreme pressure and after protracted argument. This frame of mind is most unfair, not only to ratepayers and taxpayers, but to those sufferers from conditions, often psychiatric, who are deprived of much needed accommodation by this dog-in-the-manger attitude.

Sometimes even a similar disposition may be encountered in the authorities of a voluntary general hospital, who frown at any suggestion of sharing facilities or equipment with other hospitals and are almost obsessed with the aim of making their institutions entirely self-contained. The end result is unnecessary duplication of equipment and wasteful deployment of personnel. When one has met this attitude, it is very gratifying to publicise a development in which economy and efficiency through co-ordination are being sought for.

The provision of a reliable and efficient sterilising service for any hospital is a matter of prime importance, but with every hospital doing all its own sterilising work, it is a costly item. For some time, my Department, though it was hesitant in raising the matter with the hospitals, had hoped for the development of a central service of this kind. The idea became a practical proposition when a number of Dublin surgeons, who had seen the work of a Central Sterile Supply Service in Glasgow, suggested that a similar service might be set up here, an approach which was warmly welcomed. A meeting of representatives of all the Dublin hospitals, including the health authority hospitals, was arranged and it was agreed that the matter should be further examined by a working party, which was to consist of a number of persons selected at the meeting together with some members from the staff of my Department. The working party, which met on many occasions, mostly at night, in the Custom House, has presented me with an excellent report confirming the feasibility and desirablility of setting up a central service. Copies of the report have been circulated to all the hospitals concerned and a meeting of their representatives will be held next week at which they can state their views. If the project is proceeded with, it should provide a service which from the outset will have a guarantee of absolute reliability and security and, in the long run, be more economical than the present fragmented service. Moreover, such a service could in due course be extended to all hospitals in the State.

Over three years ago, I authorised resumption of planning on two major hospital building projects in Dublin, to wit, the new Coombe Hospital on which work commenced in August last and the new St. Vincent's Hospital at Elm Park on which work commenced recently. When I was introducing the Estimate for 1962/63, I commented on the slow progress made in the re-planning of the St. Vincent's project; nothing which has occurred in the meantime has induced me to change my view in that regard. However, it is a good thing we have been able to get to the stage that work has been actually resumed on the project.

Excluding works on county homes, to which I shall refer later, the total value of the hospital building works, the planning of which I authorised, as circumstances following the financial crisis of 1956 permitted, amounts to approximately £10 millions, about £7½ millions of which will be met by grants from the Hospitals Trust Fund. The estimated cost of works completed or in progress within the £10 millions programme is about £6 millions. Apart from the two major Dublin projects I have mentioned, this figure covers a wide variety of works throughout the State. Instances are the extension of Erinville Maternity Hospital, Cork, the installation of the cobalt unit at St. Luke's Hospital, Dublin, a new paediatric unit at the Rotunda Hospital, Dublin, major schemes for accommodation of mentally handicapped children at Delvin, County Westmeath and at Cregg, Sligo, various works at Galway Regional Hospital, admission units at Cork and Castlebar Mental Hospitals and other works at the mental hospitals at Grangegorman, Letterkenny, Portlaoise, Enniscorthy, Killarney and Waterford.

Tenders have been approved for a major extension at the National Medical Rehabilitation Centre at Dún Laoghaire, for a new maternity block at the County Hospital, Castlebar, and a new nurses' home at the County Hospital, Kilkenny. Tenders in connection with a scheme of extension at St. Vincent's Home for mentally handicapped children at Lisnagry, County Limerick, have just been received and are at present under examination. The actual construction work on all these schemes, the cost of which is estimated at almost £½ million, should, therefore, commence within the next month or so.

Projects at the stage at which tenders have been invited but not yet received, or at which it should be possible to invite tenders inside the next six months are estimated to cost over £1.3 millions. The largest single item in this is the major scheme of extension at Sligo County Hospital which for certain specialties will then become a sub-regional centre. Other major items are an extension of the National Maternity Hospital at Holles Street, a new nurses' home at Portrane Mental Hospital, major works at the South Charitable Infirmary, Cork, and Jervis Street Hospital, Dublin, a new admission unit at Clonmel Mental Hospital, and a scheme of adaptations at St. Joseph's Home for Mentally Handicapped at Kilcornan, County Galway. Of the grants from the Hospitals Trust Fund amounting to £7½ millions involved in this programme, over £5 millions or 66? per cent will be payable in respect of projects in voluntary hospitals.

Much has been done, by raising the standards of nursing care, of dietary, of decoration, of furnishing, and of sanitary accommodation in county homes to improve the lot of patients. I cannot say the same in regard to the progress which has been made with the programme of radical improvements which was designed to bring accommodation up to what could be regarded as an acceptable standard. Originally it had been thought that little more than the reconstruction of the existing structures would be required. On detailed examination of the existing buildings, it was found that many of them had inherent defects which either could not be eradicated at all or eradicated only at very great cost. In such cases there was no reasonable alternative to new building. The progress of planning has had to be altered accordingly and this has made delays inevitable. In many cases this re-planning is nearing completion or has been completed, wholly, as in the case of the Home at Mountmellick where construction work is in progress on a comprehensive scheme costing about £250,000; or in part, as in the case of the Home at Stranorlar where new, single-storey, accommodation for 98 chronic sick patients is in course of being built as part I of the major scheme.

Experience has led me to accept with some reserve forecasts of the time needed before any project can be brought to tender stage; but I can see no reason at present why it should not be possible to invite tenders for the following works in the periods indicated:

Before 31st March next: Castleblayney—Comprehensive scheme.

In the April/June quarter: Clonakilty—Chronic sick (100 beds), central services, staff unit and full central heating. Ennis—Chronic sick (200 beds), convent, and central heating.

In the July/September quarter: Athy—Comprehensive scheme. Longford—Chronic sick (94 beds), central services, central heating. Trim—Completion of comprehensive scheme.

In the October/December quarter: Castlebar—Chronic sick (230 beds), convent, staff home, central services and central heating. Roscommon— Chronic sick (200 beds) and central heating.

The cost of the county homes schemes is met, as most Deputies know, by borrowing from the Local Loans Fund and health authorities have recouped to them from the Vote, half the loan charges involved, subject to an overriding maximum cost per bed. The aggregate cost of the schemes, which are already in progress or which should go to tender within the next year or so, is of the order of £3 million. In addition to the schemes I have enumerated, planning is at various stages in relation to other schemes and I expect that after the end of the next year there will be a steady flow of further works going to tender, until all our county homes will have been brought up to an appropriate standard.

I have dealt so far only with schemes that are included in the approved building programme, that is, schemes for which funds have been promised. The problem, however, does not end there. Further schemes, most of them highly desirable, have been put before me, on which the total outlay would be in the region of £15 million. Moreover, we must budget in the long term for other inevitable expenditures as well. Without anticipating in any way the recommendations of the Commissions on Mental Illness and on Mental Handicap, it is probable that they will suggest that greatly improved facilities are required in the fields which they are at present exploring. Further, if the moneys were available, the position of the teaching hospitals and the accommodation problem in the case of nursing staffs would also merit very special attention. Thus, to achieve a final solution of our hospital problems in the matter of physical accommodation will entail a staggering financial outlay, beyond our immediate resources. Consequently, I have no option but to apportion the funds at my disposal in an ordered manner; and this compels me to issue certain warnings to the promoters of hospital projects.

The first of these I have given frequently already. It is that it is a waste of time and effort to try the technique of the fait accompli. I will not in any circumstances pay any portion of the cost of any project undertaken without my prior approval. To do so would be grossly unfair to hospital authorities—and there are many— which abide by the rules.

The second is that once approval has been given for any project, the hospital authority concerned must ensure that the planning is carried out with dispatch. In selecting its consultants, the hospital authority should ensure that they will be in a position to proceed expeditiously with the work. Otherwise, I may not have any option but to relegate the project to the end of the queue or even to cancel a grant already authorised.

The third warning is that hospital authorities must be practical and eschew any grandiose notions. In the difficult financial situation obtaining we cannot hope to provide every amenity and every facility that would constitute the ideal hospital. On the contrary, economy must be the keynote in our approach to hospital building; and, accordingly, we must content ourselves with modest and reasonable standards. The drop in income from the most recent Sweepstakes as compared with the previous year, when coupled with the heavy revenue deficits of the voluntary hospitals, is a forcible reminder that building on a pre-war scale is out.

With regard to the details of the Estimate for 1963-64, Deputies will observe that, including the two Supplementary Estimates, the first of which is now before the House, and the second of which will be taken immediately this token Estimate is disposed of, there is an increase of £1,133,660 over the Estimate for 1962-63. This increase, to all intents and purposes, is attributable to Subhead G which, with the amount in the Second Supplementary, provides for a total of £11,330,000 in grants to local health authorities in aid of their expenditure on health services. The total revenue expenditure by health authorities in the current year, after allowances for receipts such as charges for services, is now estimated at over £22½ millions.

Over the past year or so, representations have been made to me from a number of quarters regarding the proportion of the cost of the health services falling to be met from local rates. As Deputies will be aware, the statutory provisions governing the apportionment of these costs between the Exchequer and the local rates are contained in the Health Services (Financial Provisions) Act, 1947. This revolutionary piece of legislation was a milestone in the history of the health services; I say "revolutionary" because in fact it revolutionised the system whereby the health services had been financed up to that time. Prior to the 1947 Act, local finances had borne by far the greater part of the cost, being supplemented only by modest State grants—grants which, apart from their modest size, had the further disadvantage that they could not be disposed of as the local authorities themselves might think fit but had to be applied to limited specific health purposes. In terms of money, the Exchequer grants represented at £900,000, a mere 16 per cent of the total cost of the services being provided. Thus the local authorities were paying 84 per cent of the cost of the health services before the present system of financing was introduced. By virtue of the 1947 Act which I have mentioned, this 84 per cent has been reduced to 50 per cent and, though it is the fact that, partly because of rising costs, including staff wages, and partly because of greatly expanded services, the actual costs have risen substantially since 1947, the fact remains that the Gross National Product has risen enormously and that proportionately, the allocation of costs has been adjusted heavily in favour of the local rates.

In the year ended 31st March, 1957, the average rate for health services, including mental health, in county health districts was 12/4d.; this had increased to 15/11d. for the year ended 31st March, 1963. The comparable figure for county boroughs shows an increase from 16/11d. to 19/9d. Thus, in the six-year period since 1956-57, the health rate increased in the county council areas by 3/7d., on average, and in the county borough areas by somewhat less. When due allowance is made for the increase in costs, particularly salaries and wages, and the striking improvements, over that period, in the facilities available for the treatment of the sick in our modern hospitals it can hardly be said that this increase is unduly large.

Despite the fact that interest in this matter of increases in the rates has concentrated largely on the health services, what must not be left out of account is the fact that the local rates in respect of other major services have increased in much the same proportion. A similar upward trend is, for instance, observable in the case of housing; in the year 1956-57 the housing rate in County Carlow was 1/4d. in the £; by 1962-63, it had increased to 5/5d. In County Donegal, the housing rate was 3/- in the £ in 1956-57; by 1962-63, it had risen to 4/10d. In Cork County Borough, the housing rate rose from 3/1d. in 1956-57 to 6/5d. in 1962-63; in Dublin County Borough, it rose from 4/3d. to 5/8d.; in Limerick from 5/11d. to 6/5d. and in Waterford from 2/3d. to 6/3d. Under the heading of General Purposes, the same upward trend is visible; in Longford the rate under this heading for 1956-57 was 6/5d.; by 1962-63 it had increased to 9/7d. The figures for General Purposes in Louth in the same years showed an increase from 4/5d. to 6/5d.; in Mayo, from 6/3d. to 8/8d.; in Tipperary (NR) from 7/4d. to 10/8d.; and in Wexford, from 5/7d. to 8/10d.

Part of the reason for these increases has, of course, been that, in general, the tendency is to expand and improve services—a movement which, I am happy to report so far as the health services are concerned, the health authorities themselves wholeheartedly support.

The hospital services are by far the largest element in the cost of the health services. As will be seen from the details in Part III for Subhead G of the Vote in the Book of Estimates, it was originally estimated that they would cost £15,060,000 in the current year. To this figure must be added a further expenditure by health authorities of £790,000 in respect of which an additional Health Services Grant is provided for in the second Supplementary Estimate, to be taken in conjunction with this Estimate. The total anticipated expenditure by health authorities on hospital services in the current year is, therefore, the formidable sum of £15,850,000.

This, however, does not represent the total cost to public funds, even ignoring capital expenditure, of the hospital services. To that figure must be added the amount which it will be necessary to add from the Hospitals Trust Fund to make up the revenue deficits of the voluntary hospitals. It is estimated that that figure in respect of 1963 will be £2,200,000.

It was never contemplated that sums of such magnitude would be diverted from the Hospitals Trust Fund for the purposes of keeping the revenue accounts of the voluntary hospitals in balance. The progression in the size of the deficits, year by year from 1956 onwards, is interesting. The figure for 1956 was £920,000—I quote the figures to the nearest £10,000—in 1957, it was £960,000; in 1958, it was £1,100,000; in 1959, £1,190,000; in 1960, £1,440,000; in 1961, £2,040,000; in 1962, £2,160,000; and in 1963, it is estimated as I have said, at £2,200,000. The cost of maintaining patients in the voluntary hospitals, as in the case of the local authorities' own hospitals, has been increasing steadily, in part due to increased staff costs and in part to advances in medical science which now make it possible to treat and to cure patients for whom previously little could have been done. The revenues of the voluntary hospitals, however, have not been keeping pace with the expenditures, largely because health authorities, who are liable for the cost of treatment of the vast majority of the patients, pay for them at rates which are completely unreal, and in most cases far below what it would cost them to maintain the patients in their own hospitals, even if they had the facilities to do so.

While the deficits were increasing at this spectacular rate, the capitation rate, excluding the supplement payable in respect of services of visiting medical staff, paid by health authorities to all the major hospitals in respect of in-patient services rendered by these hospitals, remained at 18/- a day from 1956 until April, 1962, when the rate was increased by 6/- for the teaching hospitals and 3/6d. for the non-teaching major hospitals. These increases were barely sufficient to cover the eighth round of increases in salary granted by the hospitals to their staffs, in line with the increases granted by local authorities to their local staffs, and a further increase in the capitation rates was long overdue when they were again increased, with effect from 1st October last. These last mentioned increases account for £170,000 of the increase in the Health Services Grant being provided for in the second Supplementary Estimate.

As Deputies will be aware, the capitation rates are being further increased with effect from 1st April next but as no provision for any expenditure arising out of that increase is included in the Estimate now before the House, I presume I would be precluded from dealing with that matter until next year's Estimates are under discussion. It is not only for the increased cost to health authorities of services given on their behalf in voluntary hospitals, however, that provision has to be made in the second Supplementary Estimate. According to the most recent information supplied by the health authorities, the cost of services in their own hospitals in 1963/64 will be greater by £430,000 than had been originally estimated. The largest single item in that figure is £170,000 for salaries and wages. Drugs and medicines account for a further £50,000 approximately. The balance is spread over miscellaneous heads.

When one comes to consider the hospital service strictly in the financial context, one must accept that while this is "big business", one cannot apply to it the yardsticks which are appropriate to industry and commerce. The businessman can readily assess the degree of success achieved in his year's work by reference to the financial return which it has yielded. For hospital management there are no such clear guide-lines, and the spur to greater efficiency is, in most cases, the rather crude and negative one of financial stringency. Yet in spite of the difference in objectives between business concerns and hospitals, they share a need for good and effective administration. Some branches of hospital activity such as catering and laundry work would, of course, pose problems similar in many respects to those met with in commercial undertakings operating in these fields. Not only in regard to services like laundry and catering, but in all branches of the hospital organisation, there can be no argument about the value of a frank look at each job that is being done to establish the need for it, or of engaging in a painstaking search for the best and most economical way of doing whatever it is clearly necessary to do.

Since the war there has been growing recognition in business and industrial management of the need for constant analysis and improvement of working methods. The application of work study methods in the hospital setting has lagged behind but in the past few years both in Great Britain and in Northern Ireland these procedures have been successfully applied in hospitals and many improvements in methods have been secured. Through the initiative of the Institute of Public Administration an opportunity has been offered to a number of those concerned with hospital management in this country to learn from those engaged in hospital work study elsewhere something of the methods employed and the improvements to be secured through the application of these methods. I am satisfied that in the long term the consistent application of modern management techniques coupled with the dedicated work of the medical and nursing staffs will ensure that our hospital services will provide the highest standards of treatment and care for the patients under conditions of maximum efficiency and convenience of operation.

The expansion and improvement of the health services in recent years is reflected in the increase in the number of medical and other personnel employed. For example, the overall number of wholetime medical staff employed by health authorities has increased by more than 30 per cent since 1958, the greatest proportionate increase occurring in the mental health service. With increased staffing requirements, it is essential that an adequate supply of suitably qualified candidates will be available for local authority posts. Difficulty is experienced from time to time in the recruitment of doctors in the house officer grade in our local hospitals. This may be due partly to a bias which, inexplicably, appears to exist among medical graduates against accepting employment in these hospitals and partly to the inducement offered to our young doctors to accept lucrative posts abroad. With our limited resources, we cannot compete on equal terms with wealthier countries in the matter of remuneration and conditions of employment. But to those who wish to live and work in their own country, however, we can say that there are openings in our expanding services which offer reasonable standards of remuneration and working conditions.

In the last two years, with a view to showing young people studying for the medical profession the scope and standard of the work being carried on in local hospitals, a scheme was introduced under which medical students in their fourth and final years were offered employment in the local authority hospitals during the college vacation periods. Forty-six students in 1962 and 84 students in 1963, mostly in their final year, were engaged and the reports on the results of the scheme were so encouraging that it is being repeated this year. I would stress that the aim is not to replace or dilute the resident medical staff, but rather, as I mentioned, to provide students with an opportunity of acquiring at first-hand, knowledge of conditions so that they will be encouraged to take up posts in local authority hospitals after graduation.

Because of the limited amount of funds available for dental services and the insufficient number of dental surgeons available to health authorities, it has not been possible, much to my regret, to provide a comprehensive dental service for eligible persons under the Health Acts. The position in regard to recruitment has, I am glad to say, improved somewhat. As an essential step in the further development of the service I have approved of the appointment of chief dental officers in Dublin and Cork, and senior officers in Limerick, Kerry, Donegal, Mayo, Waterford and Galway, and hope to persuade the remaining health authorities to make similar appointments, where appropriate.

During the debate on the Estimate for 1962/63, I mentioned that the National Organisation for Rehabilitation had agreed to operate a national hearing-aid service for persons eligible for aural services under the Health Acts. The service is now obtainable at the organisation's premises in Ballsbridge, Dublin, but I regret to say, despite urgings by my Department, health authorities have been rather slow to avail themselves of it. It is to be hoped that in the coming year there will be a considerable improvement under this head. In association with the hearing-aid service, the organisation will provide an educational advisory service for the benefit of children and this will be backed by the arrangements now made by health authorities for ascertaining, early in life, what children have defective hearing.

I wish that I was able to do much more to ameliorate the condition of those, particularly children, whose hearing is defective. But two things are needed for the expansion of the service: money and trained personnel. So far as the latter essential is concerned, we have had to start from almost absolute zero; and it has been slow, sometimes almost frustrating, and expensive to acquire a sufficiency for the launching of the present service. And as for money! Well, the attitude of the main Opposition, not only toward the last Budget, but even toward the recent Vote on Account, indicates that they will do their utmost to persuade the taxpayer not to provide it; and this is tantamount to denying to those who suffer from deafness, the benefits which we could otherwise make available to them.

Cheap tripe.

There is none so deaf as he who will not hear.

Open your ears.

The Minister put that little bit into his brief, and it did him no credit.

As the question of disabled persons' allowances was the subject of a recent debate, I presume no Deputy wishes me to take up the time of the House by going over the ground again, or by discussing the cognate matter of infectious diseases allowances. I should, therefore, go on to conclude as quickly as may be, were it not that there are still a few matters, including new developments, which call for comment from me.

The first is the £4,000 to be provided under Subhead F for the expenses of a Committee on Dental Caries and Fluorides. My intention was that in co-operation with the authorities of University College, Cork, this Committee, during the next few years, would carry out a special scientific survey to measure the effect on the incidence of dental caries of (a) the use of fluoridated water, (b) topical application of fluoride and (c) a combination of fluoridated water and topical applications of fluorides. As the work of the Committee is closely related to the question of the fluoridation of public water supplies, which is at present under consideration in another place, it would, perhaps, be inappropriate that I should enlarge on the matter at this stage except to say that the Committee has not yet been able to commence the Survey.

The field work associated with the nation-wide survey which the Medical Research Council has undertaken to ascertain the incidence of dental caries in school children has been completed, and three reports covering the Dublin, Kildare and Wicklow area, the Cork, Limerick and Waterford area and the Counties of Louth, Wexford, Laois and Galway have been presented to the Oireachtas. Reports on the remaining areas are at various stages leading to publication and will be published as soon as possible. The results are consistent with those recorded in the reports already published and confirm that dental decay is widespread among the school children of the nation.

While I am on this subject, I would bring to the special notice of the House a use which was made, and one which I did not contemplate when that Act was being enacted, of the Health (Corporate Bodies) Act, 1961, during the year.

The Act in question authorises the Minister for Health to establish a body "to perform functions in, or in relation to, the provision of a health service or two or more health services". Arising out of the Report of the Visitors appointed by the British General Dental Council on the inspection made by them of teaching facilities and arrangements at the Incorporated Dental Hospital of Ireland, in other words, the Dublin Dental Hospital, it was necessary to make arrangements to alter the constitution of the governing body of the institution. This reorganisation was primarily one for the Minister for Education. After consultations with the three teaching bodies concerned, that is to say: University College, Dublin, Trinity College, Dublin, and the Royal College of Surgeons in Ireland, as well as with the authorities of the Hospital, an agreed scheme was settled. To give effect to this scheme, it would have been necessary in the normal course either to amend the memorandum and articles of association of the Incorporated Dental Hospital, or to deal with the matter by legislation. In either case much time would have been required. It was necessary, however, to bring about the change without delay, and as the hospital, in addition to its teaching functions, provides a health service, I agreed to the use of the machinery of the 1961 Act.

The Incorporated Dental Hospital passed the necessary resolution for the purposes of the Act on 16th July last and on the following day I made an Order under the Act entitled the Dublin Dental Hospital (Establishment) Order, 1963, and appointed a new Board for the Hospital. The Board, as provided for in the Order, includes two nominees of University College, Dublin, and one nominee each of Trinity College and the Royal College of Surgeons. The other appointments to the Board were made in consultation with the Minister for Education. The temporary nature of the arrangement is emphasised by the fact that the Order provides that the members of the Board will hold office only until 31st December, 1964. By that date, a decision will have been taken whether the hospital should continue to operate under an Establishment Order or whether special legislation should be introduced.

I may say that, according to my information, the new body is functioning smoothly. Considerable improvements in physical facilities for teaching, and incidentally for treatment of patients, pending the building of a new Dental Hospital, planning of which is proceeding, have been effected and the Board has, after advertisement, selected personnel for appointment to a number of senior teaching posts. The persons appointed will, in accordance with the arrangements made by the Minister for Education, hold appointments as well on the staff of the three licensing bodies mentioned.

Another matter to which I should refer is the training scheme for health inspectors. The House may perhaps recall that in 1962 I mentioned that the question of essential training for health inspectors was under consideration. Subsequently, in October of that year I set up a special Board, composed of representatives of the Departments of Health, Agriculture, Education and Local Government, of local authorities and the Dublin Vocational Education Committee, to organise suitable courses of training.

The course, which is full-time, will extend over a period of four years and will combine theoretical instruction with practical training in the field. In the co-ordination of theoretical instruction and practical training, the Board have the services of a trained Health Inspector Tutor from the local authority service. Formal instruction is being provided under arrangements with the Dublin Vocational Education Committee; and the students, who are assigned as trainees to the Dublin Health Authority, receive practical training there and with other local authorities as well. On completion of the course to the satisfaction of the Board and having passed the necessary examinations, students will be awarded a diploma which will be a recognised qualification for the purposes of appointment as health inspector.

Allowances of £150 per annum, increasing by annual increments of £25 to a maximum of £225, are paid to the student trainees. In addition, provincial participants receive an allowance towards subsistence at the rate of £2 a week.

The first course of training organised by the Board commenced in January, 1963. Ten students selected by the Board after advertisement are participating. A second course, for another ten students similarly selected, commenced during the year.

When dealing earlier with the maternal and infant care services I referred briefly to the "thalidomide" problem. Partly as a result of this problem, and partly as a result of the proliferation and increased use of drugs by the general public, concern at the dangers inherent in the free availability of medicinal substances containing poisons has been increasing, here and elsewhere, over the past few years. On the other hand, the right of responsible individuals to have reasonable, and, all things considered, inexpensive access to safe specifies and well-tried remedies cannot be disregarded.

To assist me in deciding what restrictive measures were necessary in the public interest, I have asked the advice of Comhairle na Nimheanna, the expert advisory body established under the Poisons Act, 1961. The Council's first task was to review the existing legislative controls over poisons, some of which go back to close on a century ago. The Dáil will appreciate that so comprehensive a review cannot be completed in a short time. I believe, however, that when it is completed, we shall have a basis of a poisons law which will be flexible and adaptable to the requirements of to-day. Meanwhile, however, after consultation with Comhairle na Nimheanna I made the Medical Preparations (Control of Sale) Regulations, 1963, and thereby brought a number of potentially harmful substances in rather more widespread use amongst the general public under control.

You did not include cigarettes in that?

No, no. The regulations provide that for the purchase of any drug in a group of some 29—amongst which are those commonly known as tranquillisers—a doctor's prescription is essential; and that 25 other substances, for which a doctor's prescription is not essential, will not be obtainable otherwise than through qualified pharmacists. I think I have covered all the ground to which these Estimates relate and I hope the House will see its way to pass them.

I move:

That the Vote be referred back for reconsideration.

There are certain matters in the long statement the Minister has made on the administration of his Department to which I propose to refer. We approve and applaud the programme of research into certain aspects of the cancer problem which he informed us has been embarked upon at St. Luke's Hospital. We believe there is scope for research in this country along those lines, perhaps not on the vast scale that such research has been undertaken in the United States and Great Britain but there are aspects of the problem to which no doubt we can make some contribution.

The Minister has referred to the carcinogenic effect which it is alleged cigarette smoking has. This aspect of the problem has received so much publicity I often think there is a grave danger of overlooking another aspect of the problem of lung cancer which may have equal importance, that is, air pollution. It does seem to be pretty clear that diesel fumes can create a predisposition to cancer of the lung and I have seen it suggested from a Scandinavian source that it is not impossible that a predisposing cause may be pollution of the air and the precipitating cause excessive cigarette smoking superimposed on the predisposition created by the presence of polluted air.

It is, of course, necessary to maintain strict vigilance in regard to cigarette smoking but it would be a pity if our attention became exclusively riveted on that possible cause of lung cancer to the exclusion of prudent inquiry into how far air pollution contributes and, if it is established that air pollution makes a contribution, an inquiry into how far we can correct by suitable controls the pollutions which are at present taking place.

It has to be borne in mind that in the memory of most of us here there was very widespread industrial pollution of the air which precipitated lethal fogs in certain industrial centres. That became so acute and so manifest a problem as a result of the bronchial symptoms it precipitated that in Great Britain and the United States of America very drastic measures have been taken to restrict the burning of soft coal in certain urban areas. There are now large areas in both Great Britain and the United States where the burning of soft coal is not allowed at all. Forty years ago, it would have seemed unthinkable that such regulations could ever have been successfully recommended to the public, but the manifest association between that kind of air pollution and acute bronchial symptoms makes this restriction necessary. The direct connection between diesel fuel oil air pollution and lung cancer may not be as manifest and obvious but if it is a true source of this terrible affliction, it is very necessary that it should be identified so that we can start the necessary publicity to prepare the public for such measures as might become necessary in order to avoid the continuance of that kind of air pollution.

I learn with great satisfaction of the striking reduction in the total number of deaths from all forms of tuberculosis. That is one of those problems in connection with which great risks were taken, great financial commitments entered into. Great doubts were expressed from the threshold of that campaign as to whether our radical approach to it was not too extragavant and too reckless. It is a matter of great rejoicing that the resolve to use the sources available to us to the limit of our ability in 1948 and in ensuing years has yielded so abundant a harvest of people saved from death. It is something of which we have every reason to be proud that we faced that problem when we did and were not afraid to undertake the expenditure necessary and the legislation necessary to produce the eminently satisfactory results on which we can now congratulate ourselves.

I want emphatically to endorse the appeal made by the Minister today that we should not become indifferent to the remaining problem of tuberculosis. It could be substantially abolished if people would avail of the national mass radiography service. It would be a tragedy if we allowed a chronic source of infection to remain that could be eradicated if we could persuade the public to collaborate in the measures necessary to control it, and probably one of the most effective of all measures is availing of the National Mass Radiography Association services.

I think it is important in that connection and I would ask the Minister to remember our history in this respect. I understand that one of the strange manifestations of the present tuberculosis situation is that a good deal of the infection survives in middle-aged people and that when we began this campaign for the eradication of tuberculosis, we were dealing with the disease of the young. We are now dealing in a large degree with the disease of the middle-aged.

Two factors require to be borne in mind in connection with this matter. One is that in the minds of our people tuberculosis is not associated with middle-age. Most of our people feel that if you have not had tuberculosis in the first three decades of your life, you will never have it. Therefore, it does not occur to the people in later middle-age, in the fifties and sixties, that they can acquire the disease and can be sources of infection. I think that fact has to be emphasised so that the public mind may fully awaken to that danger. What is far more important is that when the middle-aged of today were young, tuberculosis was still a secret thing. I can well remember when I was young, in any part of rural Ireland, if a young person was found to be suffering from tuberculosis, that person's family stoutly denied the fact and maintained a fiction for protracted periods to the great detriment of the whole family that the child had not tuberculosis at all but was merely delicate.

The reason for that was that they associated tuberculosis in those days with a fatal illness and we had good reason to know that in all too many cases it was a fatal illness. Even where it was not a fatal illness, it was associated in the minds of the people with the idea that if they went away to a sanatorium, they were away for years. The fact now is that with modern drugs and efficient sanatorium treatment, people have been restored to normal activities in an astonishingly short time. I have known of cases of people in middle-age who were unexpectedly discovered suffering from tuberculosis, who went into a sanatorium and in six or nine months were restored to active life completely cured.

It would be of great assistance in helping to clear up this problem of middle-age tuberculosis if we could publicise and emphasise the fact that this is no longer necessarily a disease requiring indefinite hospitalisation but that it can reasonably be expected to yield to treatment in a relatively short time with the restoration of the tubercular patient to a normal life. I emphasise that fact because it is so easy for us to forget the atmosphere that surrounded tuberculosis 30 or 40 years ago and that atmosphere is still enshrined in the mind of the middle-aged patient today.

I am shocked, as I have no doubt the Minister is shocked, by the maternal and infant mortality rates. I cannot understand why the maternal death rate here should be more than that in Great Britain, Scotland or Northern Ireland. So far as I know the services here are just as good. The Minister has simply said that this is a fact but he has not given an indication of why it is a fact. I am even more astonished at the infant mortality rate here and I am quite at a loss to know the reason for it. What is the situation pertaining in this country which justifies so wide a gap between the infant mortality rates obtaining here and those in Great Britain? Here it is 29 per 1,000 as compared with 30 per 1,000 in 1961. The corresponding rate in England and Wales is 22 and for Scotland and Northern Ireland it is 27. Has anybody discovered what is the reason for the vast discrepancy between England, on the one hand, and Scotland and Northern Ireland, on the other?

There are various conjectures but they have not been proved.

It cannot be housing.

As I said, there are various conjectures.

Is it not odd that there should be such a difference?

It is open to investigation.

It seems odd that there should be this discrepancy between the figures for Scotland and England. What mystery is there to account for this discrepancy? The conditions north and south of the island should be approximately the same.

One factor is that a very large number of our children come late.

That does not obtain in Scotland?

I do not know whether it does or not.

It seems an odd thing in an island like Great Britain with one Government, one system of social services, and one system of medical services, to find that in England and Wales, the infant mortality rate is 22 per 1,000 and that across the border in Scotland it jumps to 27 per 1,000.

The social conditions are very different. The Deputy has only to think of the vast expanse of sparsely populated districts in Scotland, as compared with Great Britain, where the availability of medical care is less.

They have neglected areas the same as we have here.

No, there are not neglected areas.

I should be glad to hear from the Minister, in the course of his concluding statement, such information as is available to him for this strange disparity. There are large areas of sparsely populated districts as well as industrial areas in England and Wales, while in Scotland there are also largely populated industrial districts as well as sparsely populated districts. You also have much the same housing conditions in both England and Scotland and yet you have this remarkable disparity. As the Minister says, it is largely due to scarcity of maternity services in rural areas.

I did not say "largely". I think it is one of the factors but I shall deal fully with that in my reply. I have already dealt with it in previous debates. There are a great many factors causing this disparity.

I think it would be useful to have a word on it.

I thought I tried the patience of the House enough this morning.

It is in some degree reassuring to know that the infant mortality rate is on the downward trend. It is some encouragement to find it at 29 as compared with 30 in 1961 but it is a mystification to me why there should be this wide disparity between the averages in England and Wales and the figures here because I do not know of any inferiority in the maternal care provided here as compared with that provided in Wales and rural England. However, I suppose the Minister will give us the best information he can when replying. I am glad to know it is still engaging the Minister's attention, as it certainly engages ours.

Is there any explanation of the continuing high incidence of gastro-enteritis? We had an alarmingly high figure some years ago and then the figure went down to something approaching normality but it now seems to be going up again.

The Research Council have been trying to find out the reason for this. Certainly nobody has been able to give me a reason for it. They are not able to explain it to themselves.

There is universal pasteurisation of milk in Dublin—I do not think there is any raw milk sold in Dublin. Without being controversial, or without seeking to be controversial, I wonder is it associated with housing?

It may. I do not think so, because housing conditions are considerably improved compared with what they were during the war. It was a very serious problem during the war.

Then it went down. I thought it might be associated with the building of houses.

We are dealing with organisms which tend to defeat therapeutic measures.

I wondered if gastro-enteritis were associated with inadequate housing facilities.

Is it associated with the incidence of such things as piggeries beside houses?

They are being dealt with.

We shall all be glad to know the result of the research council's investigations. Certainly no one will in this House allege that any Party is indifferent to the incidence of gastro-enteritis. It is our common interest to control it, and it is discomforting to us, especially when we cannot put a finger on its cause, that there should be an increase at a time when we would expect a steady decline. The Minister spoke of the thalidomide problem in association with births. Have there been a large number of abnormalities?

A significant number. "Large" is a relative term. There is difficulty in correlating deformities with the use of the drug.

It is one of those disasters that overtake us from time to time, and we can only hope that anything we can do to alleviate the circumstances of the children concerned will be done, and I am sure it will. I am sure all sides of the House will agree on that.

There is an important matter in regard to poliomyelitis. The Minister has announced that, having consulted his advisers, he has now come to the conclusion that oral vaccine for poliomyelitis is safe and effective. There is one aspect of this matter on which he did not touch, and on which it would be wise for him to touch. Many of us have had our children vaccinated with the Salk vaccine, and the question arises: does the oral vaccine now serve effectively as a booster to the Salk vaccine as originally administered?

I think it does. I shall not commit myself until I have verified my impression.

Those who have had their children originally vaccinated with Salk might be reluctant to use the oral vaccine unless the matter is clarified.

There is another matter to which I should like to refer in connection with the Minister's reference to occupational training, and his reference to provision being made for mentally handicapped children. In these two contexts the Minister has spoken of occupational therapy and the other devices which are being employed to help mentally afflicted children. I wonder has his attention been directed to the special problem of the autistic children. I am told that in dealing with mentally retarded children, you can segregate a type of mental affliction to which the title autism has been given, of which we might expect to find in our society, according to statistical calculations, perhaps 500 or 600. I understand experience teaches that there would be about three boys for each girl.

I am informed that if we could identify those children at an early stage, much could be done to prevent them becoming hopeless, chronic mental cases in their maturity. It is one of those peculiarly tragic forms of mental affliction on children who have an external appearance of normality and, indeed, exceptional physical beauty up to their second or third year. There then ensues a period of great doubt and difficulty in which it is extremely hard to determine with precision what is going wrong until ultimately it is established that the children are abnormal, and fall into the class of autism.

If those children, for a variety of reasons into which it is not necessary to go in detail now, are not removed to an institution where, in the majority of cases they can best be catered for, there is grave danger that unless their special circumstances are catered for, they will deteriorate in maturity to the condition of chronic schizophrenics for whom virtually nothing can be done. If in their childhood they can be given special tuition and training, and if in their adolescence, which is a critical stage, they can be given guided occupational therapy, they can be effectively rescued from the tragic fate of chronic and incurable schizophrenia, and while probably never becoming capable of restoration to normal society and uncontrolled activity, they will be capable of useful activity and a relatively normal life in a suitable home under trained direction.

I recognise that much as one's heart is moved by the tragic circumstances of mental affliction in children, one must temper sympathy with reasonable prudence. I am greatly strengthened in my recommendation to the Minister of special attention for this problem by the knowledge that I am not asking him to undertake some new and heavy financial commitments, because if those children are not looked after in the way I suggest, they will end up as life-long inmates of mental institutions, and in the category most difficult to provide for, requiring constant day and night attention, as chronic schizophrenics only too frequently do. All I am suggesting to the Minister is that we should have one or two institutions, possibly one in Cork and one in Dublin, for boys and girls, which would, in fact, cater for those patients who otherwise must be catered for in the general mental hospitals, where it is very much more difficult to give them the special kind of attention which could rescue them from the fate of chronic and deteriorating mental affliction.

If the Minister indicates to me that his attention has already been directed to this problem I hope he will be able to tell us, when concluding, that this special problem does permit of his sympathetic and optimistic consideration, with a view to providing for this limited number of children treatment that would save them from ultimate schizophrenia and chronic mental affliction.

I note with interest that the Dublin Health Authority has made available to the County Wicklow Health Authority the sanatorium premises at Newcastle as a mental hospital for County Wicklow. I want to remind the Minister of the time when he used to jeer at us because we were building so many sanatoria.

You have been very nice so far.

It is good to remind the Minister of those things. We took a great risk and spent vast sums of money on building so many sanatoria that we can now boast that some are standing idle for the reason that there are no patients to go into them. That I regard as the apotheosis of all our hopes and work and from it two facts emerge. One is that tuberculosis has been reduced to a very minor problem today and we are now engaged in trying to track down and eliminate the last remnants of it. The second fact is that we were right in believing that when these sanatoria had served their purpose of destroying the hydraheaded monster of tuberculosis, they could be used as mental hospitals.

Surely you are not claiming that you built the Newcastle Sanatorium?

No, but I am claiming that the sanatoria we built can be used to advantage when they have served their purpose of eradicating that dreadful scourge which used to be the nightmare of us all. I rejoice that the hospital at Newcastle has been converted to a mental hospital. I applaud it and I think it is an admirable thing to do. I hope it may be possible that as other institutions of this kind become redundant, we may be able to divert them to such specialised uses under the general mental treatment programme as I have been advocating. I can assure the Minister that in any difficulties he may have with certain local authorities regarding the conversion of these institutions, he will get all the support we can give him because of our purpose that when these sanatoria had completed their work, they should be converted to other uses in the general pattern of the health services.

Perhaps the Minister would indicate to us, when concluding the debate, whether he considers that sanatoria in any other areas will become available for the accommodation of mental patients both for the purpose of segregation to which I have referred and for the relief of the great pressure that exists at present in many of the existing institutions.

I heard with great interest the Minister's announcement of the establishment of a specialised sterilisation service in Dublin. This is a highly technical matter and it is not one on which I wish to express an opinion. It is almost incomprehensible to a layman who has always regarded sterilisation as a definite matter for those in the operating theatre alone. I hope the Minister will give us some further information when he is replying.

I will be glad to deal with that matter. The really gratifying aspect of the matter is that it was organised by the Dublin surgeons themselves.

It is also a matter for the layman for it is the layman who is going to be operated on and he will always want to be reassured. They will want to have it explained to them how it is that a central sterilisation unit can service a number of hospitals. In the last paragraph on page 20, the Minister says that such a service could be extended to all the hospitals in the State. I find it very hard to understand how that can be done. I hope the Minister can reassure the public generally as to how asepsis can be maintained and as to how supplies can be carried to hospitals remote from the sterilisation centre.

I am going to pass over the Minister's remark regarding the attitude of this Party to the expenditure of money. It reminds me of the attitude of the Taoiseach in Cork claiming that the policy of Fine Gael was a restrictive one which advocated reductions in expenditure at the cost of progress. At the same time, his son-in-law, the Minister for Justice, was in Kildare claiming that the programme of Fine Gael would involve the State in such expenditure that it would cripple it forever because of the multiplicity of benefits it contained. I think this little hoot from the Tánaiste belongs in the same category of unrewarding comment.

There is another matter in the Minister's statement which causes me great concern, that is, the programme for the reconstruction of all the county homes in the country. I want to renew for consideration by the House a sentiment I have expressed on more than one occasion and I want to renew it with special urgency in the light of this programme which it is suggested will cost many million pounds and which is designed to perpetuate the county home in rural Ireland.

I have lived all my life in rural Ireland and I know that one of the perennial horrors that affect life in rural Ireland is the discovery that some old friend and neighbour is no longer able to look after himself or herself in his or her old home. I want to engage the Minister's special attention on this matter. All of us in rural Ireland are familiar with the picture of the old people, men and women, commonly living, man and wife, together. The man has worked all his life and now they both have got the pension. Then the old woman dies. He is alone in the house and the neighbours visit him. Gradually, the normal picture is that the house gets dirty and people concerned more with efficiency than humanity say: "Old Charley ought to be got out of that house; he is not able to look after himself".

Those who understand the position better get the nuns to come in occasionally to clean up the house, or a neighbouring woman comes in. Then, the next day the neighbours, bringing him a bowl of soup, find that he has fallen in the fire. He is burned. An attempt is made to provide precautions, but then some other accident happens and the neighbours say: "We cannot go on like this; some morning we will wake up to find poor old Charley has fallen in the fire and that he is dead".

Then comes the tragic dénouement: old Charley has gone to the county home. We can all find an old neighbour like Charley, living in abject misery, cold, hungry, and we say to him: "Is it not time you went to the county home?" You will find he is prepared to go to any resort to avoid it. It is a very common illusion that it is because he does not want to leave the particular hovel into which his helplessness and poverty have reduced him. I believe that is not the fundamental cause. It is the hideous prospect of isolation.

I know this because all of us in public life from time to time visit such institutions. I have gone into county homes and been called by somebody in bed who, quite frankly, I thought was dead for years. He had disappeared from the neighbourhood, had gone through all this agony and had been forgotten and then you discover him suddenly, utterly alone. He is clean; he is warm; he is fed. Physically he is in much better condition than when you last saw him, but mentally, and in all the ways that matter most, he is destitute, because the last time you saw him he was longing to live and now is he longing to die but cannot die.

He is longing to die because he feels utterly isolated, utterly useless and rightly feels he is utterly forgotten. All this could be resolved if we could provide what already exists in many country towns in Ireland, parochial homes. They are all over the country. The interesting thing is that they were established by old charities in the sixteenth and seventeenth centuries and they still survive. Compare the state of an old person living in those charities—close to his home, where neighbours constantly visit frequently, where he is able to potter out himself on a market day or go round the town to buy a spool of thread and live in the normal life of the society into which he was born and reared—with the same person's experience in a county home.

I do not want for a moment to denigrate or make little of the valiant service that is given by those who run our county homes. I always remember with veneration and gratitude the lady who was the matron of the county home in Roscommon for many years. I remember going into one of the wards with her on one occasion which was filled with old people, difficult, complaining and, as they often are, unappreciative of her efforts. I said to her: "Mother Paul, I often wonder how it is you spend your life at this", and she said: "If I did not see the face of God in each of them, I could not". But she did, and devoted her whole life to it most sublimely. She was wrestling with a problem she could not resolve. She could feed them, clean them, bear with their crankiness, but the one thing she could not give them was the feeling of being near their neighbours, of being remembered, of being part of the society to which they normally belong.

Am I peculiar in this? I think I am right. What puzzles me is why we set out again on the perpetuation of the poorhouses, which were wholly alien to our outlook, the relic of a deplorable and fatuous attempt to solve the Famine and a wholly mistaken idea of how the Famine problems should be dealt with. Why is it? Is it that it is more economical to do it in this way? I do not think it is. I believe if you had a parochial home, run on the same lines as the old charities were run, you would get the desirable situation that some of the inmates would help the others.

If you had a lady superintendent, you would virtually not want any staff at all. Perhaps you could have the dispensary nurse to help the lady superintendent in such institutions and they, with the assistance of the ambulant inmates, would carry on very well. I believe such a system would work extremely well. Everybody would be happy and this perennial horror of moving old people to the county home would be resolved. The Minister himself must have some knowledge of this detestable situation.

You will find a young fellow getting married in the family home and his young wife understandably failing to get on with the boy's mother, or very often with the boy's father. Then there is the horrible story that they have shifted the old mother to the county home. Mind you, that is a relatively rare situation, but it does happen. There are many homes made extremely difficult by the fact that there is an old woman or an old man in the house with whom the young woman cannot get on, and the family are disrupted and there is a great deal of domestic woe because the old person in the house will not go because he knows if he goes to the county home what he is going to.

Instead of that prospect opening before him, he could have this prospect of going into a parochial home such as the charities to which I referred can provide. If there were institutions of this kind associated with the parish, and perhaps annexed to them three or four flats, you would frequently find that elderly parents would gladly go to them and make some weekly contribution out of their pensions or savings in order to facilitate domestic peace in the old home when the new wife comes in.

Is it too late to examine this whole problem and see how far we could substitute, if possible, parochial homes for county homes or, if that be impossible on the grounds that certain of the inmates of the county homes are, in fact, really people who require hospital treatment, could we not reduce substantially the number of people who have to live well-fed, well-looked after but in the circumstances which make them long for death because they are lonely? I am satisfied this is a very great social problem. I am certain, unhappily, that those most afflicted by it are not in a position to make their voices heard. I am certain there is not a county home in Ireland where perennial tragedy is not being endured and I am certain we could do something about it and it would not involve intolerable expense. I should be glad to hear the Minister's reaction to these representations because I have the uncomfortable feeling that, if we commit ourselves to the expenditure of millions on the reconstruction of county homes, we will never be able to face all the social implications of that decision. We are going on shipping the old and poor into unwanted years of survival—unwanted by themselves, because such survival is only an ordeal of loneliness where it could be a really happy decline in intimate association with their neighbours and friends and the atmosphere which, taken together, represents home for them.

I feel very deeply about this, because I speak from a great deal of personal experience in regard to it. If there is one duty which I find peculiarly distressing, it is to visit the county home, because I have the feeling that here is something about which I can do very little. Possibly to see a familiar face does them good, but you sometimes feel when you call on them that it only makes them lonelier than they were. It revives their nostalgia for home and home sickness, and those of us who have been home sick as children know the insufferable agony of that sentiment. I can never go to visit friends in the county home that I do not wonder if I would be better to stay away. Yet one goes back because one cannot bear to forget them altogether. The shock which I have had more than once is to be saluted by somebody whom, in fact, I believed to be dead.

I feel sure these problems are pressing to the minds of other Deputies who live in rural Ireland. I do not know what the corresponding situation is in the city of Dublin, but I feel that here in Dublin, even if people have to go into institutions, they are near their own. They are still in Dublin; they hear the Dublin accent around them; the whole life of the city goes on around them, and their neighbours can visit them. Their problem is not as acute. But take somebody who lives in Emyvale who goes to Castleblayney, or somebody who lives in Kilmovee and goes to Roscommon or Castlebar. I do not think I need further paint that picture. It is a living death.

The old, the poor and the unwanted —these are the people for whom we should be solicitous. I am sure every Deputy would feel the same anxiety for them as I feel. What puzzles me is the paralysis of the will to go out and do something about this. Is it that we forget it? If that is the reason, we should not forget it. If that is the only reason, I think this problem could be, if not completely resolved, substantially mitigated. I would urge on the Minister, before we are irrevocably committed to very large expenditure for the reconstruction of county homes, to see if some of this could not be devoted to expanding the existing service of charities designed to keep people near their homes where, whatever other afflictions they would have to suffer, they would not have to face loneliness and home sickness as well.

The rules of procedure do not permit us to discuss matters which would involve legislation. Nevertheless, the House will remember that our approach to this whole health problem is different from that of the Minister for Health. Another occasion will present itself for discussion of the fundamental differences which are not strictly relevant to the administrative matters appropriate to this discussion. I should be grateful, when the Minister is concluding, if he could deal with the matter he has already undertaken to deal with and, most especially, if he could give us his thinking on the future of the county homes and the alternative accommodation which we might be able to make for the old, the poor and the lonely.

The Minister's statement was a fairly comprehensive one, and I do not propose to deal with all the matters he mentioned. However, I propose to comment on certain of the problems to which he referred. We have all our own ideas as to what the priority should be in tackling our health problems. My ideas may not correspond with the views of other Deputies, but I feel sure the short list I have in mind would meet with the approval of the House. The House may not accept the list in the order I give it, but I do not think there would be much disagreement about it.

Deputy Dillon referred to one of the points, namely, the problem of our old people, who are being sent to what I can only describe in the majority of cases as dungeons of county homes. Another problem shelved for years which must be faced is the problem of the mentally handicapped child. The third problem of major importance in my opinon is one that will need immediate attention and at the same time is a long-term problem—the problem of mental health. The Minister himself, in his statement, has admitted that it is a grave problem in Ireland and it is a pretty serious thing when the Minister, in writing, has to admit that "among European countries we have an unenviable record in this regard". That is the cause of so much of our mental health problems. In fact, from the statistics available, I believe that we have the worst record in Europe in regard to mental illness.

The big problem of the past ten years which various Governments tackled was the TB problem and, to a great extent, the back of that problem has been broken. The time is now over-ripe when a crash programme, as vigorous and inspired as the TB programme, should be undertaken to catch up with other European countries in their attempts to solve the mental health problem.

The Minister has said that every effort is being made on the basis of our present knowledge to remedy the position by continuing to improve and expand treatment. I do not accept that for a moment. If the rate of progress operating in the mental institutions which we know—the general ones throughout the country—is the yardstick by which we measure progress it will be another fifty years before we catch up with our next-door neighbour in solving this problem. I notice that the Minister has admitted first that our record——

The Deputy should not misconstrue what I said. I said that the number of persons in mental hospitals constituted the unenviable record, but a great many persons who are in mental hospitals should not be there at all. They are not ill; they are senile.

And there are many who are not in mental hospitals who have not far to go to reach that condition.

He is not here today.

I did not say that present company was excepted. The Minister has put his finger on one of the difficulties. We have, up to the present, quite large numbers of people being held in these mental hospitals who should be released and sent home. I know for a fact that when such action is being contemplated by progressive medical men it is flouted by the reactionaries in control in many of these institutions. But the Minister cannot excuse the position here by suggesting that, because we have quite a number of old people in our mental hospitals who should be at home, this increases the figure of those shown as suffering from mental trouble over and above the European average. That is not correct, if we accept what the county medical officers throughout the country say in their annual reports.

There is a definite problem of mental illness in certain parts of Ireland. I think the Minister will admit it has nothing to do with age groups. I should like to know if the commission of inquiry which is examining the problem of the mentally handicapped is examining into the causes of mental illness. Is it examining into the problem in Ireland as to why the percentage of those suffering mental illness is higher than in other countries? Surely it should be the other way about.

Much boasting is done in this country that the suicide rate is lower than in certain other places that have a higher standard of living and perhaps far better social services, but that is poor consolation if we have a higher percentage of mental deficients in Ireland. Why is that? Is an examination being made of the causes of that or are the Government afraid of such an examination? A proper examination should be made of the sections of society who suffer from mental illness and the various categories of it. The sad position is that when you look at the various sections today under treatment in the mental hospitals, in certain categories there is a large percentage of breakdowns? Why is it that the stress of living is hitting so many people here although we are not such a highly developed community industrially? If our position is so serious and we are not a highly developed country—if it is accepted that the more developed the country is and the faster the pace of life, the higher the rate of mental trouble—why is our problem greater than in many countries that are highly industrialised and where the stress of living is so arduous? What will it be like if we are brought fully into the 20th century by proper expansion of our industry and agriculture?

The Minister has said that there is not anything so depressing as the spectacle of a large number of patients sitting around in day rooms and corridors in a mental hospital doing nothing. What does he mean by that? To whom is it depressing—to him and those who come in as onlookers, or to the patients themselves?

I am glad the Minister has clarified that point. Is he satisfied everything possible is being done in the mental hospitals without doing any building work to ensure that lack of activity is remedied?

I have gone on a hot summer day to visit a patient in a certain mental hospital. The doors and windows on the outside were all locked and in the community room were about 80 patients, women from the age of 16 up, walking up and down, sitting on chairs and looking at the ground or looking at the walls. There were one or two nurses inside reading newspapers or magazines while there was a broiling sun outside. To my mind, that is criminal so far as the treatment of patients is concerned in mental hospitals. It does not involve the expenditure of large sums of money to solve, or at least ease, that problem. A little commonsense and understanding would solve it by getting somebody to open the doors and bring those patients out for a walk on the lawn or even let them sit outside in the sun.

It is no wonder that so many people become depressed and institutionalised in mental hospitals. They are locked up and that is the end of it. I do not say that that is the position in all our mental hospitals. An excellent outlook is apparent amongst those in charge in some of them and every effort is made to make life easy and to ensure a rapid turnover in the numbers being treated.

I only hope that the example set by the top-class mental hospitals will be followed without delay by the other institutions or by the mental hospital boards in various centres. Very often, it takes quite an amount of prodding to get these people moving.

At some of the monthly meetings of boards of mental hospitals, the main items of discussion can be the amounts paid for different types of meat and arguments about whether such meat should be produced on their own farm. I have often seen at a mental hospital board meeting a big detailed list of the commodities purchased by the farm steward and wondered whether it was an agricultural meeting or a mental hospital board meeting. Sometimes, the last thing thought of at such a meeting is the welfare of the patients. Such matters need examination.

The Minister should have no compunction about giving a rap on the knuckles to those boards which are not doing their duty. He is not very shy about giving raps on the knuckles to local authorities, very often on the wrong issues. He is not suffering from shyness when it comes to this matter. The Labour Party will put no obstacle in the way of the Minister in respect of financial accommodation in any steps he takes to improve the situation in the mental health field.

The problem of disabled and mentally handicapped children is very serious and very sad. I can talk at this stage only for the west of Ireland, particularly my constituency. What I say may sound parochial but I hope my experience is not the experience of other Deputies in other parts of the country. I shall be interested to discover if that is so.

I have been a member of a local authority for the past 12 or 14 years. During that time, I have used whatever influence I had, through criticisms and through prodding, to bring home to those in charge the necessity for increasing accommodation for mentally handicapped children and for increasing the number of trained teachers to look after them. There has been very little improvement in the past 12 years in that respect in my county.

What must be thought of us as a nation when we are so neglectful of our weaker and younger sections such as the disabled or mentally handicapped child? I have letters from parents, month after month, begging me to use my influence to get a child into some institution before it is too late so that treatment will be given to it. If the Minister consults the Roscommon local authority he will find that my experience is, I presume, that of every county councillor on that local authority. The staff of the county council are most helpful so far as trying to persuade the few institutions available to take in such children is concerned. The county medical officer of health in Roscommon has admitted that many children in the county today will never be placed in institutions in time to give them a training or a chance in life. The sad part of it is that it is not such a terribly expensive job.

Apart altogether from considering the welfare of those unfortunate and unlucky youngsters who are disabled or mentally handicapped, there is the terrible problem that parents fear for the welfare and safety of the other children in the family. In quite a number of homes, a mentally handicapped or disabled child may be a danger not only to himself but to his brothers and sisters. I know of no priority for such children to be taken away and given a chance in life.

I argued this point a few years ago in this House and pointed out that we would have to go outside the existing channels available in our institutions. I was told that the situation in England would not be adopted here and that we should be delighted to have the Brothers of the Order of St. John of God to do this work. I am well aware of the excellent work they are doing but if these Brothers have not the facilities to look after all of the children I speak for, then the State must step in and see that people who have a vocation for this type of work are allowed to train and are given jobs in Ireland in this very important field.

There is a shortage of accommodation and of therapy instructors in the west of Ireland to look after mentally handicapped and disabled children. The Minister should lose no time in facing this problem. He spoke here of running up against difficulties in finding other uses for some of the sanatoria——

No—there is no difficulty about finding other uses but there is a difficulty in getting——

——there is a difficulty in persuading local authorities to put vacant sanatoria to other uses. The Minister cannot be blamed if he can say that local authorities are preventing him from using accommodation which is lying idle and which could now be used for the rehabilitation and training of these children. If that is true, if the Minister is accurate, he has a duty to tell the House where these health authorities are and let public opinion deal with them. If the public knew the facts, knew that a local authority was holding up the transfer of an institution which could be used for these sad cases which I have mentioned, they would deal with the members of that authority in no uncertain fashion at the next county council elections.

To come nearer to the west of Ireland, the Minister has been pressed by Roscommon County Council to consider taking over a building or an institution in Galway for the training and accommodation of these children. I should like to know from the Minister if he has made any progress in Galway. The suggestion by our local authority was that there should be a regional centre in Galway which would cater for the surrounding counties in Connacht. I know that there has been an improvement in the Sligo area but as far as Galway is concerned, if an existing establishment were taken over and staffed, it would solve the immediate problems in Roscommon and other parts of the west.

I would urge the Minister to move in that regard because it is depressing to have to wait for ten or 12 years and see no apparent improvement and at the same time see the waiting lists there each year. It is disgraceful that public representatives should have to say to parents: "I am sorry, I can do nothing about it. I am not in a position to get a bed for you in any of the existing institutions; they are packed out and there is no hope of your child getting in in the next two, three or four years." That is a terrible answer to have to give to any parent. I would not mind if it only had to be given once but to have to give it year after year to different parents is inexcusable.

Deputy Dillon referred to the problem of old people in county homes. I could not agree more with him in regard to the necessity for dealing with this problem. I am not, of course, in agreement with his solutions but I am in full agreement regarding the extent of the problem and the sadness of it, particularly in rural Ireland, because I cannot speak for the city areas. In Roscommon, we have a county home which dates back into history. For the past ten years, the local authority have been pressing the Department to sanction a new building to house the old people who are in the existing home. I do not know where the blame for this delay lies but I should like the Minister, if it is not too much trouble, to let us have the facts in the course of his reply because I can tell him he is being blamed for the delay. As far as the local authority are concerned, they are told that the Department are considering whether there should be ten or 15 more beds in it and each time the local authority officials are pressed about the matter by the county councillors, they tell them that the Department want another consultation. There are nothing but consultations going on between the officials of the county council and the Minister's officials. As far as I am concerned, and as far as the people of the county home are concerned, there does not seem to be any improvement or any prospect of finality.

I know that the Minister stated that he hoped to see accommodation for 200 people built around October. I want to put it to the Minister that in the planning of this accommodation, the greatest possible consideration should be given to the comfort and the happiness of those who will be housed there and who will end their days there. In my opinion, it is not necessary to build a fortress or to use the normal methods of building construction in order to provide an excellent hostel for old people. The Minister is aware that there is a new building technique available now which would halve the cost of putting up an excellent hostel. This question of cost has been brought up time and again by the Minister and by other people who say that the country cannot afford this, that or the other thing. I suggest to the Minister that he can provide a first-class building with first-class accommodation by the use of new building techniques and can do that at half the cost of building by normal methods. I want to emphasise that the adoption of this new type of building should not mean any delay in planning.

The situation in Roscommon is pretty grim. It is sad to go into the county home and find the old people segregated. The impression we get when we go in is that we are in an institution. There is no feeling at all of its being a home. That is a very important thing to remember; it is a problem that must be solved. I know that the good Sisters who run county homes do their best but their best is not good enough. As far as I am concerned, whatever may be said about the vocation of looking after county homes, the main thing to remember is that we must ensure that the old people in them are happy. Their lives in the county homes must not be purely a matter of the next world, for at least while they are in the homes, they must be given some little comforts. I do not like to see old people being kept indoors and practically locked up and only let out once or twice in the week. That is a disgraceful way to treat people when they go into a county home.

We have to face the fact that many people, many of the younger people, take the view that old people are a burden to them. The first thing they consider doing is putting old people into the county home. I cannot give the Minister a solution to that problem. To me, that is a sign of sickness in the minds of our people. Our mentality with regard to disabled people and mentally handicapped children is disgraceful. Our outlook on the matter is disgraceful. Our outlook towards old people is equally disgraceful. In other words, if I may put it this way, we have, I think, no Christianity at all in our approach. Our neighbour who has been described as pagan, or whom a great many hypocrites in this country anyway, like to describe as pagan, is far more sympathetic towards the needs of the weak, the old, and the disabled, far more understanding of their problems, and far more willing to sacrifice, shall we say, little luxuries in order to ensure that those who are weak get the benefit. Here, in Ireland, if one asks that something should be done for old people, or that they should be helped, the answer is: "We cannot afford it." It has been the case over the years that, whenever there is a saving to be achieved in the rates, one can always be sure that the county home gets a rap. I do not know what one can do with that outlook. The only thing we can hope for is that those who know better will set a good example, and the Minister and his Department should try to set an example in this regard.

I mentioned the new type of building technique which is available to the Minister. Apart from utilising this for the county homes, he should also, I think, remember that in hospital building a far closer watch should be kept on the advisers, on the architects, and on the engineers. I know that the Minister is a layman. I know that a layman is not in a position to decide finally, perhaps, what type of building should be erected, what type of accommodation should be made available in a regional hospital. In fact, huge sums of money have been wasted in the methods used and in the planning and building of regional hospitals in this country. I shall give the Minister an example.

The Regional Hospital, Galway, was built to cater for a big area. Those who planned it were alleged to have the foresight to know what the demands on that hospital would be, the extent to which it would be used, and the number of beds necessary. That hospital is now overcrowded and there is no possibility of reshaping the building to accommodate more patients. There are long corridors there which could be turned into first-class wards, long corridors over which one would need skates in order to get up and down in any kind of time. There is a whole series of private wards, single bedded. These rooms are slightly too big for one and too small to hold a second bed, even in case of emergency. They show a lack of proper planning. If these rooms had been made smaller they would still be big enough to accommodate one patient; if they had been made slightly bigger they could accommodate two beds, if necessary. Their present size is wasteful. That clearly shows bad planning.

There is bad planning in many of these hospitals from the point of view of the siting of the kitchen and the provision of cooking facilities. It strikes me no consultation at all takes place between the planners and the people who must use these particular hospitals. I refer to those who have experience in big hospitals of the problems of staff, of cooking, of long distances between various wards, et cetera. Is the advice, I wonder, of these people taken into account at all by these brilliant architects, engineers and officials when they get together round the conference table to make a final decision on the building? I do not believe it is, but there is nothing so valuable as the experience of those who have a practical knowledge of running these institutions, or hospitals, and I suggest to the Minister that he could save quite an amount of capital outlay by consultations at the proper time and by paying heed to those who will have to work in these hospitals.

The Minister referred in his statement to the position of the voluntary hospitals and to the fact—it is, in my opinion, an extraordinary situation that he should have to admit this—that they are not too anxious to co-operate.

I did not say "the voluntary hospitals". I said "some" and "occasionally".

Occasionally. "The" means all of them en masse, but I say there are exceptions.

There are exceptions to everything.

The Minister is not so easy to get on with himself at times.

Oh, no. I have a point of view. That is the point.

I shall quote the Minister:

Sometimes even a similar disposition may be encountered in the authorities of a voluntary general hospital who frown on any suggestion——

I said "sometimes". The Deputy made a general comprehensive statement bringing in every voluntary hospital authority, which is not what I said.

I will accept what the Minister says: not every voluntary hospital is included. The position, however, is bad enough for the Minister to mention in his report that, sometimes, certain voluntary hospitals are not prepared to co-operate — I will accept that—although the State is paying the deficits of these voluntary hospitals each year. This is a situation the Minister will have to have examined very carefully. He has stated that for the present year the figure for deficits of the voluntary hospitals that will have to be met by taxation up to 31st March is £2.2 millions. The Minister says, and I shall quote him because I want to be very accurate in this:

It was never contemplated that sums of such magnitude would be diverted from the Hospitals Trust Fund for the purpose of keeping the revenue accounts of the voluntary hospitals in balance.

Each year the figure for deficits in the voluntary hospitals is mounting and, as we know, the Minister has no control whatever over these hospitals. It is an extraordinary state of affairs that large sums of money, and this is something that was never contemplated, are handed over to the voluntary hospitals while, at the same time, no control good, bad, or indifferent, can be exercised over them. Wherever public money is being spent the Minister, or the State, has a right, in my opinion, to see that that money is spent properly. The State has a right to intervene to ensure the money is spent properly and no institution can describe itself as voluntary if it is dependent to the extent that the voluntary hospitals are now dependent on the public and on the State for the payment of their debts. They cannot have it both ways. The Minister should have this matter very carefully examined with a view to seeing that those who pay the piper call the tune. There is nothing unreasonable about that proposition.

The final point I should like to make to the Minister is in connection with the cost of drugs. He has stated that in the present year the increased cost will be £50,000. That is a heavy increase but even without that increase, the cost of drugs is exorbitant. I believe the public are not able to pay the cost of these drugs, especially the middle-income group. It is heartbreaking for families to have to pay for very expensive drugs and, as the Minister knows very well, all the prescriptions are very dear here.

The Minister will probably say that he issued a circular to the local authorities which enables them to ease the burden on the middle-income group where drugs are prescribed over a long period; in other words, that a limited medical card may be given to such a person. The fact is that that circular would never have seen the light of day were it not that it was dragged out of the county council officials' files. They were forced to agree that such a provision was there. The general public are not aware of this and it is only the rare case that is getting the benefit of that power which the Minister states the local authorities have to give a limited medical card.

I do not intend to deal with this question in detail but I do want to emphasise that the Minister himself should inquire into the possibility of bulk buying of these medicines. I am told that quite a number of these drugs can be bought in bulk at far lower cost than they are available here at the present time. A number of hospitals in England do their own bulk buying outside Britain, and one leading hospital in Britain is able to buy abroad its requirements in medicines and drugs at half the price at which they could acquire them through the normal channels in Britain. I should like to know if the Minister and his Department are probing into the possibility of acquiring from abroad these very costly drugs and medicines in bulk form at the most economical price. Something will have to be done in that regard and I hope the Minister will have something to say on that. There are other matters in the Minister's statement with which other Deputies will deal and I shall leave any further comment in the general field to a colleague of mine.

I should like to thank the Minister and his officers for the manner in which they have presented their brief. It is well spaced which is a great convenience to people like myself who wish to make notes on it. I would commend the clear presentation of this brief to the Minister's colleagues.

The Minister stated he was alarmed at the incidence of deaths from gastro-enteritis in children which is exceptionally high in Dublin city. Deputy Dillon mentioned that when housing improved ten or 12 years ago, the incidence dropped and he thought that might have something to do with it. The Minister pointed out that it was a matter of the germ. I would say to the Minister it might be the milk still and it would be well worth while to check on all the pasteurisation places around Dublin to see if they are pasteurising milk according to the standards expected by the Minister's Department. That is the first thing. Then—I have some public experience in this—it might be that the young mothers might not be using the facilities that are there for them in their new houses of scalding everything they use. It would be no harm for the Minister to make inquiries along those lines.

As regards mental illness, a group of people in my constituency of Waterford are doing great work for mentally handicapped children. I shall not take the Minister to task in this regard because I know the great problem with which he is faced in staffing the institutions for rehabilitating these children. I know the Minister will help these voluntary organisations in Dublin, Cork, Waterford and elsewhere because they are composed of people who have the right, Christian idea. They are prepared to give their time, money and attention to this problem. I know there will be requests to me from those people in my constituency and I would ask the Minister to give them well-deserved attention.

There are many people in our mental hospitals, some of whom are old and senile but others of whom are not really mental patients at all but are there because they are unwanted at home and have nowhere else to go. That is a problem for the local authorities who do not want to put these unfortunate people out. It is dreadful that many people, when their fathers and mothers get old, only want to get them out of their way.

That brings me to what Deputy Dillon said about the care of the old and about the county homes. I have visited county homes in my day. I have always felt the staffs of the county homes are doing the best they can and show great devotion to the people under their care. I think it is something that came down from the old system. I do not know whether it is the system or the rigid discipline. Many of those old people might have been very rich, entertained people at home perhaps, and then found they had no better place to go than the county home. They brought their independence with them and the regulations were such that many of them reached a stage when they only wished to die. They were always dissatisfied and, I may say, grief-stricken when people from their own area called to see them. There is something to be said for having these kinds of homes in various places and I am sure when the Minister goes to his officials, they will reiterate what I am about to say.

In Waterford city, we can proudly say that the people have shown themselves to be more than generous. From generation to generation they have shown themselves to be more generous than in any other part of Ireland. We still have a great many homes for old people in Waterford. Some of them were left to us by merchant princes. Some of the homes were left by very decent Protestant gentlemen and Protestant charities, and by retired sea captains.

We still have a great many of these homes. They are well run. We have the Little Sisters of the Poor who, when they came to Ireland, paid us the compliment of coming to Waterford first. There they knew they could make a start. They have a fine institution and they look after people from all counties around. The people are happy there and are well looked after. They have a certain amount of freedom and can go out to the pictures.

Then we have another type, a charity which was set up by moneys left by Captain Walsh and it is a substantial building. Old ladies have flats there and have a matron to look after them. They get a small sum of money every year but they bring in money with them. They look after themselves and can go and come whenever they like, the only restriction being they have to be in by a certain time of night. This is the type of institution I would recommend. We have an institution which was left to the parish priest of Ballybricken and the Christian Brothers. Old ladies are looked after too. We have the Widows' Committee of the Burton Institute and the Matthew Shea money left by Captain Shea. The men have their own rooms and can go out to the pictures, and so on. The freedom they have is of great help to them. When they are ill their companions look after them under the supervision of the nuns.

The last one I propose to mention is worthy of mention because of the way it has endured and come down to us to do the great work it is doing. It is known as the Holy Ghost Hospital. We have that since the dissolution of the monasteries. When the monasteries were dissolved here in Ireland by Henry VIII an enormous amount of people were unwanted because the monasteries were a refuge, not only for the poor but for the rich people or anybody who happened to be around, but especially for homeless people. A Waterford merchant offered a sum of money for the great friars of the Franciscan Abbey to the King's Commissioners.

The King himself accepted the offer and gave some adjoining lands to help maintain it and the Abbey was to be opened for a home for old people. Mass was to be offered and the rosary said every night for the donor. It was one of the extraordinary places where Mass was offered at all periods during the Elizabethan persecution and the Cromwellian persecution and continued until the middle of the last century when the Abbey buildings were in a bad way. Great men, such as Edward Leamy, came and pulled the estate together, and were able to make it pay to such an enormous extent that they were able to apply to the Commissioners for Charitable Donations and Bequests for help and they built the new building known as the Holy Ghost Hospital.

It is a beautiful building on the Cork road. There are 12 cottages surrounding the building. They are semidetached cottages with a living room, bedroom, w.c. and a little kitchenette. They are for old couples, while inside, in the building proper, the men, or the women, have their own rooms, their own church, their chaplain and two John of God nuns to look after them. Revenue comes from the rents and the governors are the Aldermen of the City of Waterford and the Bishop of Waterford and Lismore and the Bishop of Cashel, that is, the Catholic and Protestant Bishops, and a Life Master is Mr. J. J. Walshe who happens to be a namesake of the founder. But there it is. The people, instead of having to suffer the agony of going into the County Home, and having to go long distances away from their homes, would, if there were homes like this, run in the same way, and under the supervision of the Government, be able to live in their own rooms and go to the dining room and get their meals or, if they wished, cook their own meals. They have freedom which is not given in the county hospitals. They can go out to the pictures, to sports fixtures, football matches, and so on. I might add the inmates still recite the rosary every night for the donor, who happens to be Henry VIII. I told that to a Franciscan once during a discussion on the Abbey when he mentioned Henry VIII. I said: "Of course they say the rosary every night for Henry", and he said: "Good God, you do not tell me they do that, but maybe the poor man would want it."

I do not think that arises on the Estimate for the Department of Health.

It would be a good thing if it did as we might get a subvention from the Minister, such as Henry VIII gave us to run a home for old people. I say the Minister would have to be in the position of Henry VIII and would have to give a subvention. Then maybe the people would say the rosary for the Minister. Perhaps he will need it sometime.

The Minister pointed out that the rates went up on other services besides the health services. He said:

A similar upward trend is, for instance, observable in the case of housing; in the year 1956/57 the housing rate in County Carlow was 1/4d. in the £; by 1962/63, it had increased to 5/5d. In County Donegal, the housing rate was 3/-in the £ in 1956/57; by 1962/63, it had risen to 4/10d. In Cork County Borough, the housing rate rose from 3/1d. in 1956/57 to 6/5d. in 1962/63.

The Minister's predecessor, Deputy Dr. Ryan, invited the local authorities to a central region to get their co-operation in the health services. The local authorities of Munster were invited to Cork, and I had the honour of being selected by my local authority to go to Cork. The then Minister specifically told us in Cork that the charge would be 2/- in the £ on the local authorities if they adopted the health services. That was definitely said, and it was definitely the reason the local authorities agreed to the terms of the new health services. Some members who were there, including myself, asked the Minister was that the figure, and he said it was. I asked was there any danger it would go up to 3/-, and the Minister said: "No." I asked was there any danger it would go up to 4/-, and he said: "Not at all." I could show the Minister cuttings from the various newspapers which appeared the next day. I would have had them with me today but the Estimate took me somewhat by surprise. I have them on my file.

In 1952, the rates struck for the health services—I know they were not very good health services—ran from 1/3 to 1/6 to 2/- in the £. The health services are now costing the local authorities around £1 in the £ and, in some cases, 26/- in the £. It is not the Minister's privilege to wash his hands of that whole business. I know the health services are exceptionally good, and I know the local authorities are prepared to play their part, but, in view of the Minister's undertaking, the local authorities consider they are carrying too much of the burden.

The health services of which I have had experience are excellent. I should like to pay tribute to the specialists, and I should like to pay tribute to the Minister's Department for the specialist services. They are doing wonderful work. Some wonderful operations have been performed, and children whose limbs were deformed have been restored to health and made perfectly normal. Those are wonderful operations.

The Minister mentioned doctors, health inspectors, dental surgeons, and various persons connected with the health services, but I notice he did not mention the nurses. When replying, would he tell us what his policy is towards the nurses, and if he is prepared to meet them in what they are looking for? We often brag about things about which we have no right to brag and say we have the best in the world of such a thing. We can proudly say our nurses are among the best in the world. They are welcome in every country, and their hours and conditions of pay should be equal to any in the world.

I seldom listened to a statement by a Minister with such interest as I listened to the statement made by the Minister this morning. With the exception of one or two minor comments of his own, which might have been left out, and with the exception of the fact that the Minister has a flair for using three big words where two small words would do, I think the document is a very fine one. It is a factual statement, and it will be very useful to Deputies for comparison purposes in years to come.

The Minister might have put a little more emphasis on the killer diseases. I am sure the public would be shocked if they realised the situation. For instance, there is the fact that there were 10,974 deaths from heart disease in 1962. In the previous year, there were 11,064 deaths from the same disease. Every medical effort should be made to try to find some preventative because, apart from the number of people who die from heart disease, there are thousands who are crippled for life, and who become eventually a burden on the State. During the past year, a lot of attention has been given to cancer, particularly lung cancer. Last year 697 people died from lung cancer—a not inconsiderable figure. When we compare that figure with the number who died from heart disease, we find that the real villain of the piece is heart trouble, and the State must make every effort to try to find some remedy for it.

Somebody said this morning that the tempo of life may be responsible. It is a fact that over the past few weeks an enormous number of relatively young men and women have died suddenly. I know one area where five people who appeared to be in the prime of life passed out like a snap of the fingers. Surely this is a serious situation and one in respect of which the Department of Health must bend all their effort to find out why the figures of these sudden deaths should be so high. We have all been horrified by the deaths on the road but compared with the number of people who die from heart disease, the number of deaths on the road is nothing.

I would agree with Deputy Dillon's view regarding the causes of cancer and I believe that diesel fumes are a far greater danger than cigarette smoking. I do not know if the law is loose about this matter but there is nothing more irritating than driving mile after mile behind a lorry which is belching out diesel fumes without any consideration for other users of the road. There can be nothing more dangerous and CIE buses frequently come into this category. If there is an effort to do something about lung cancer, something should also be done about air pollution by diesel fumes in our cities and towns. In the country districts, the fumes do not linger very long.

I congratulate the Minister on trying to have something done about cancer but we seem to be taking things very easily. Recently a voluntary body was set up to assist in this effort and, while we must give the greatest credit to people who are prepared to assist in these matters in their spare time, it is my personal view that this is a matter for the State. The scourge of tuberculosis has been almost wiped out because of positive action by the State and if dealing with the cancer problem is going to cost a great deal of money, that money should be found by the State. In the long run, it will cost the State much more if we allow the present trend to continue. Hospitalisation for long periods, assistance in various forms, and the human tragedies that occur because of the two killer diseases I have mentioned will eventually cost the State very much more.

I would ask the Minister to tackle this problem in the way in which a previous Government tackled the other problem of tuberculosis. That is the only way in which it can be dealt with. Mass X-ray is helping greatly in finding people who are suffering from tuberculosis but quite a number of suspects are not inclined to avail of this service. They are not inclined to disclose the fact that they might be suffering from tuberculosis and are scared to death that they might be found to be so suffering if they had themselves X-rayed. That is a tragedy, and it should be brought to the notice of the general public that it is in everybody's interest that anyone who might be remotely connected with the disease should have an X-ray as soon as possible.

I was interested in the figures given by the Minister with regard to maternal and infant mortality. It is difficult to understand the difference between the figures for England and Scotland and those for this country. The races and the climatic conditions are very similar but possibly the fact that they have different health services may give them a slight edge over us. I should like the Minister to indicate if the figures for infant mortality are not due to a large extent to congenital diseases and that the children in many of these cases would not have lived anyway. These may be children who would not be helped even by the most modern medical treatment.

It is not clear from the Minister's statement what he means by the number of malformed children born. Does he mean that there are more of them born in Dublin? Take also the incidence of children suffering from gastro-enteritis. I do not know what is responsible for the high incidence of that disease in the city but I would suggest that there are still too many sources of infection in our towns and cities. Perhaps I may be saying something that will not be too popular in certain quarters but it is a shame that piggeries and such other sources of infection should be allowed in the middle of housing centres. Where you have this sort of thing, there is much greater danger of young children taking infection. It is a shame to see the most modern blocks of flats being built and within 50 yards of them, people feeding pigs and throwing food, dirt and filth all over the place.

I was rather surprised to find that there were quite a number of thalidomide babies in the country. I feel sure the Minister will do everything possible to give them the necessary assistance when they come to the age to benefit by it. I was glad to hear that polio appears to be on the way out. However, would the Minister say if any general instruction with regard to the new type of protection—the oral vaccine—has been sent out to the local authorities? I suggest that there is still need for an all-out effort during a certain period of each year to ensure that all children are protected.

Reference has been made to increased costs in voluntary hospitals. I do not know whether the Minister is aware of it or not, but I am informed the costs of patients in voluntary hospitals have increased by from 45 to 50 per cent in the past two years. That is a substantial increase, and while there may be an explanation for it, I do not think the Minister's explanation, that these hospitals did not benefit by any increases for some time, is the entire story.

Would the Minister say, — he referred to it in passing—if it is because of reduced sweepstake income or because more money is being channelled into the building of hospitals? If that is not the reason, I should like to know why such an extra heavy impost has been put on local rates. I am one of those who believe that when a person is ill, the important thing to do is to give him proper and prompt treatment in whatever place that treatment is most easily obtainable. That is the policy guiding most of the local authority and voluntary hospitals throughout the country.

Speaking for my own local authority, they are prepared fully to facilitate patients who live in districts nearer the voluntary hospitals in Drogheda or Dublin, if they can be treated there. The fact that during recent years we have always found the hospitals in Navan practically full means there is no objection by anybody to having patients treated in outside hospitals. However, in view of the tremendous cost to the local authority, this has become a very big problem.

During the past few days, Meath County Council have been discussing the rates for the coming year. We find there will be a further steep rise. One of the main reasons given is the extra cost of sending patients to the voluntary hospitals. When I asked why this was so, I was told it was because the Hospital Sweepstake funds were no longer available to the same extent as in earlier years. If that is so, I should be glad if the Minister would explain why.

Both local authority and voluntary hospitals are giving an excellent service, excellent treatment. When the Minister stated the voluntary hospitals are still able to give treatment in many cases at less cost than the local authority hospitals, I feel sure he must have been aware that certain local authority hospitals include some of the cost of maintenance and hospital repairs in their overall charges. That, in fact, presents a lopsided picture.

I honestly believe that the people in country districts who are now getting treatment under the Health Act to which they were not entitled some years ago have not very much to complain about in the matter of payment. I do not think that in fact they do complain very much but we find this aspect often arises and I would ask the Minister for an explanation.

I am sorry to hear that some local authorities do not treat patients in the same way as we do in County Meath. Some local authorities insist on their medical card patients going to the county hospital, which may be 20 or 30 miles from where they live, while at the same time there may be one or two voluntary hospitals beside them. They are taken away from beside these voluntary hospitals to the county hospitals. To my mind, that is an unfair, unchristian, system and I would ask the Minister to use his influence to stop it. I know some hospitals are not always full and that the local authority may feel it is a good thing to bring patients to the county hospital, no matter what discomfort it may involve for the patients. I repeat it is unchristian and unfair and I hope the Minister will intervene and stop it.

The question of county homes has been raised and in this matter I agree with Deputy McQuillan. However, the Minister has given a long list of homes about to be repaired, included in which is the home in Trim. Wonderful work has been done over the years. In all senses of the word, it has been a home for the people who have gone there. One or two things, however, make me uneasy. Deputy McQuillan referred to the fact that if a man and his wife go into a county home, they are put into separate quarters and may not see each other again in this world. If one goes into a county home any day, one will find groups of old men—not so much the old women—sitting around doing nothing but twiddling their fingers. It must be an awful long day for them. It is quite true they may go out and walk around the town, but I think some more entertainment should be provided for those in the last days of their lives. As far as accommodation is concerned—food, clothing and all the rest of it—it could not be surpassed. The good nuns look after them excellently. When paying a tribute to them and to the nursing staffs, the Minister ignored the work being done by the domestic staffs, the wardsmaids and the porters. They are the people who really do the work of catering for the old people in these homes and I think they deserve this tribute.

In some areas we have the suggestion that as the county home is not paying, as it is getting dilapidated, it must be knocked down and replaced by a modern building to be erected in any part of the county where it suits the county council. That is not a good idea. In my locality—not in my constituency—in Drogheda, something like that has been suggested. I submit it is wrong that old people from Drogheda should be uprooted and sent to the other end of the county where none of their relatives or friends can visit them.

I should point out here that everybody who goes to a county home is not an outcast, a person who has been thrown out of his home. It is true there are quite a number of people who have gone into county homes voluntarily because they feel they would be better looked after and happier there than struggling on their own trying to make do with the minor social services available to them. In most cases they are well looked after. I understand the cost of keeping them in a county home can run to £3 or £4 a week. It surprises me that somebody has not thought of giving them a few pounds extra at home, where they might be able to carry on better than in the county home.

Mental illness has been referred to. The Minister made a comment which I do not think it would be fair to allow pass. He said:

How true it is that mental illness is one of our most pressing health problems is borne out by the fact that we still have 19,250 of our people in mental hospitals. Among European countries we have an unenviable record in this regard.

I do not think it would be fair to let that pass without comment. Unless we know the standard with which the Minister is comparing us, the wrong picture could be given. We could have some of the English Sunday newspapers highlighting the fact that we have in Ireland a high incidence of mental illness. I do not think that would be quite true. I should like to know from the Minister how many of those 19,250 are people who were committed to mental hospitals when they were mentally ill but who now have nobody to take them out. For that reason, they have been left in the mental hospitals, even though they are saner than many of the people in Cork and Kildare.

In addition, would the Minister say whether we in this country are inclined to put people into mental hospitals far earlier in their mental illness? Are we prepared to put in people who are perhaps only slightly mentally deranged? In other countries I have visited, it is quite common to see in practically every village one or two of those people previously known as the village idiot. Nobody seems to worry much about them. Here they are very often put into a mental home and left there. When the Minister is making his comparison, is he taking that fact into consideration?

I know that recently most mental hospitals have been trying to segregate the children who, up to recently, have been left with the adults. I hope this trend will continue. It is shocking to see a boy of 10 or 15 years in the same ward as a lot of old men who are mentally defective while the boy may be only slightly deranged mentally. There are also the type of people who, for one reason or another, become mentally deranged now and again. I am told there are certain drugs, which, if properly used, can prevent the attacks from recurring for a long period or possibly prevent them altogether. I know a number of these people. They are excellent citizens, most of them very hard working. Then they become affected. For some reason it appears that the drugs are not always available. It is only when they have got treatment over two or three months that they are told at the end of it that the doctor will now supply them with the drugs and that they may not have to come back. The drugs have effect for a period, but eventually that dies off and the situation is worse than before, with the result that these people have to return to hospital for costly treatment. Is there any hope that the people who suffer in that way would receive continuous treatment or that there would be a periodic check to find out whether or not they are receiving treatment? It should not be left to the patients to decide. The onus is upon the medical authorities of seeing to it that the treatment is carried out properly.

As far as buildings are concerned, I honestly believe a number of the mental hospital buildings could do with a lot of renovation. It is true the cost will be colossal, but we are dealing here with the needs of human beings. No matter where the money comes from, it should be found to try to deal with people who are ill.

A number of people from Louth and Meath have come together in Drogheda to set up, with the assistance of the local clergy of all denominations and the local doctors, a school for mentally handicapped children. It is an excellent idea, and I would recommend to the Minister that the State should give every possible assistance there. At present it is being maintained by voluntary contributions by people who have guaranteed a certain sum per year for three years. I hope that before the three years are up the Department will have taken it over completely. I understand similar schools are in operation in other towns.

There is one tendency which should be closely watched in this connection. There is a tendency to take children who are easily collected and, in some places, to take children who come from a certain class of home. It would be a pity if the excellent progress being made is spoiled because one or two people at the head of affairs are inclined to pass over the poorer type of child in order to ensure that others receive the treatment which is, of course, required by all. The number of children of this type who can be dealt with by the teacher is very small. It is very costly to run a school of that kind. Therefore, every possible assistance should be given by the State to have the school properly run.

The Minister referred to the amount of money being spent on the hospital building programme and referred to the reduction in the income of the Hospitals Trust Fund. It would be a great pity if the Fund were reduced to such a state that it was unable to carry on its excellent work. If there is a suggestion—I am assured there is not —that the hospitals should be built and that the money given to the voluntary hospitals should be reduced, that is not a good idea.

The Minister also said in his speech:

The drop in income from the most recent Sweepstake as compared with the previous year, when coupled with the heavy revenue deficits of the voluntary hospitals, is a forcible reminder that building on a preWar scale is out.

Perhaps the Minister would give a little more explanation of that when replying?

The burden of the Health Estimate on the rates is referred to here. When we talk about giving hospital treatment to those entitled to it in rural areas, we should remember that the amount of money collected by the local authority hospitals over the year is in most cases incredibly small compared with the number of patients treated. This bears out the argument that a very good service is being provided by the local authorities for the amount of money paid in rates for the treatment.

I see a remark in the Minister's statement that the eighth round increase in wages was responsible for increasing very substantially the amount which the hospitals were charging. While that is to some extent true, we must not forget—although some people forget—those three letters, TOT, because the turnover tax also played a big part in the increased cost.

Progress reported; Committee to sit again.