We appreciate why the Minister did not wish to take the opportunity at this stage to outline his proposals for the future development of the health services. I hope he will appreciate why we wish to take the opportunity to do so. In fact, we have considered in very great detail the whole operation of our health services, and we have published in great detail the radical reforms which we think are necessary in our health services if we are to give the services to which our people are entitled.
I hope the Minister will pay attention to the suggestions we have made in the consideration which he will be giving to the future development of our health services. He can expect from us complete co-operation in the reforms which we think necessary, but if, on the other hand, in carrying out the review which is to be made, he brings forward proposals which are merely palliatives, or which amount to mere tinkering with the problem, he can expect from us only our vigilant criticism. I should also say that if he attempts to stop reforms, or to block reforms, in the rather callous way his predecessor did, he need not expect any co-operation from us at all.
On many occasions we have reiterated what we think are the glaring defects in our present health services. Those defects are known to anyone in the lower income groups who has had the misfortune to come up against the services and they should be known to every Deputy and every public representative.
The criticisms of the means test which have been made over the years are, I believe, fully justified. In many cases the application of the means test is carried out in such a manner as to be degrading to the applicant for the blue card. In its administration there are considerable delays, and delays occur in the renewal of medical cards which involve the unfortunate patient in uncertainty, distress and worry. As is generally known, there is great inequity in the assessment of entitlement to the blue card in different parts of the country.
Figures given by the Minister's Department to the Health Committee during the previous Dáil show that 11.9 per cent of the population of Dublin city are covered for free treatment. In Waterford city 56.6 per cent are covered, and within Waterford county, 52.9 per cent are covered for free treatment. Across the border in Tipperary, South Riding, only 32.1 per cent are covered. Certain discrepancies in the figures can be explained by a difference in the standard of living in different parts of the country, but the disparity is so great that different standards of living are not the only reason for these disparities. It is obvious that different standards are applied in different parts of the country, and that, in fact, people do not get fair treatment. It is obvious that as the system is operated, it is not operated equitably.
Of course, very high administrative costs are involved in the operation of the means test. Those costs are not only to be found in the local authorities and the Department of Health but also in the hospitals themselves, who have to maintain quite a large staff to fill in the many forms and operate the many regulations in the required manner.
Apart from the indignities and inequalities involved in the means test, there is the glaring fact that under the present system 30 per cent of our population have no choice of doctor at general medical practitioner level. The lower income group now covered by the 1953 Health Act is roughly 30 per cent of the population and for these people there is no choice of doctor. I am sure every Deputy is aware of cases where people have lost faith in their local dispensary doctor, not perhaps through any fault of the dispensary doctor but because human nature being what it is, people, particularly sick people, can easily lose faith in a doctor and for these people there is no alternative but to pay for medical services and, in addition, pay for the drugs which may be recommended. In fact, this is happening very frequently. There are poor people who have to pay for medical services because they do not for one reason or another avail of the dispensary services made available for people in the lower income group.
While the criticism I am about to make does not apply so much in the city of Dublin, undoubtedly in the country districts dispensaries are placed in positions inconvenient for those who may wish to avail of them. People may live on the borders of a county or dispensary district and find themselves within a short distance of a dispensary they might like to avail themselves of but are prevented from doing so.
I believe these criticisms of our health services are fully justified and any scheme which would assist in remedying them should be carefully considered. The criticisms of the workings of the Health Act apply not only to the lower income group but to the middle income group which comprises the majority of wage earners. We are the only western European country except Finland who make no provision in our public health services to cover the expenses of general medical practitioner care for the bulk of our population. The position at the moment is that the vast majority of our wage earners have to face, in the case of illness of themselves or their families, heavy bills not only for general medical practitioner care but for hospitalisation as well.
As is well known, there is the curious situation that if a person needs treatment in the out-patient department and if he is in the middle income group, he has to pay for it. He has to pay for any surgical appliances that may be advised by his doctors and for any operations that may be undertaken in the out-patient department and this happens very frequently. The result of this situation, I believe, is that there is gross overcrowding in our hospitals because in fact a great many people are brought into hospitals who do not need to go there. They are brought in out of the kindness of heart of the hospital authorities who say that if they are treated in the out-patient department they will have to pay for the appliances and the drugs but if they are treated in the hospital, they will get specialist services and appliances free.
This happens also in the sphere of voluntary health insurance and the result is that a great many people are in hospital who need not be in hospital. This is one of the effects of the operation of the Health Act and it involves very heavy extra expenditure not only for the hospitals but for the local health authorities and, ultimately, the Department. There are other anomalies in the health services which I hope the Minister will carefully consider. There is the position of old age pensioners who will not get benefit if the income of the family is such as to disentitle them to it.
There is another area crying for reform. It is the school medical examination which is, to a very large extent, a farce at the moment. A child is examined three times in its school life. There are no proper facilities for the examination; there is no privacy in the examination; there is no guarantee a child may be ill when the examination takes place; and, as everybody knows, the health authorities are grossly understaffed and the examinations carried out do not in fact represent a proper service.
I have touched only on the areas where I believe the defects are so obvious and require remedies. In the consideration which Fine Gael gave these matters, we believe there was one solution which would remedy these defects and we have suggested an extension of the idea of national insurance in the sphere of health and have recommended the establishment of a comprehensive national health insurance service.
It is to be strongly regretted that our proposals were criticised in the heat of the general election in the way they were. I sincerely hope the Minister, in his review of the health services and of the way in which reform can be made, will forget the ill-considered criticisms made. The Taoiseach and the former Minister for Health criticised our suggestions and used the nonsensical phrase that the health insurance proposal amounted to a poll tax.
There is only one way we can extend the health services to give the people what they need, that is, through health insurance. They have done it in other countries. There is no way in which we can bring about the necessary reforms unless we use health insurance and I give the Minister a guarantee, not only on my own behalf but, I feel certain, on behalf of all my colleagues, that we shall forget what the Taoiseach and the former Minister for Health said about the insurance principle and shall not refer to it again if in fact he accepts this principle and brings it in because there is no other way of doing it, taking into account the standard of health of the country, our system of payments to the health authorities and the general level of taxation.
If the Minister adopts this principle, he will get our full co-operation. The suggestions we have made would in fact get over the defects, the crying deficiencies, in our present system. If we had a system of health insurance, it would mean there could be a free choice of doctor for all. It would mean there would be free treatment in hospital for all insured persons. It would mean giving a free general medical practitioner service.
When I say "free," of course I know Deputies will understand exactly what I mean. We have never said the services can be provided otherwise than by health insurance and have suggested that the people would willingly accept the need for weekly contributions in respect of the services they would be given in return. We believe this is practical and that it can be worked so that the poorer sections, the social assistance class, may not have to contribute and that farmers with poor law valuations of under £15 may contribute nothing.
So, too, in the realm of child welfare, we believe very radical reforms are necessary. At present the health authorities are obliged to provide clinics only in towns with populations of over 3,000. There are many areas where there are no proper child welfare services. We have suggested and advocated the establishment of child welfare clinics for all children, from birth to the age of 16, and which should be available not just for children in national schools but all children, including those attending vocational and secondary schools. Such clinics could be staffed by the district nurse, a social worker and medical personnel, and reference could be made, when necessary, to local doctors from the clinics, or to hospitals as the case may be. We have also suggested that this country is suitable for a service, which has operated in other countries, particularly France, of mobile welfare clinics, because there are many outlying areas from which mothers cannot bring in their children without great hardship to themselves and the children. The system of a mobile service is working well in France and could be operated here without too great a cost and in areas where the need is most great.
The Minister in his opening remarks referred to the work being done in Kilkenny under the auspices of the Rev. Dr. Birch. This is remarkable work. We have in fact suggested an extension of the idea being undertaken there to the whole country. This is why we have suggested this domiciliary welfare service which we believe is so urgently needed. The case of old people is of course one of the prime needs of the present time. There are a little over 32,000 people over 65 living alone. Such a domiciliary welfare service could operate a home help service for these people. This has been developed in Northern Ireland but it has not been developed in this part of the country at all. It is not an expensive service to operate but it would require skilled social workers such as we have suggested in the domiciliary welfare service which we think should be introduced.
The Minister referred to the Commission of Inquiry on Mental Handicap and I think the thanks of this House and of the public generally are due to the members of this Commission who have reported so excellently and thoroughly on this very important problem. This report clearly indicates the urgent need for immediate action. It is not possible to ascertain the exact number of mentally handicapped people but carrying out a review of conditions on the most scientific basis possible, the Commission have indicated that as a target we must produce for our mentally handicapped people facilities based on the following figures: for severly handicapped, all ages, 2,750; for moderately handicapped children, 1,400; for mildly handicapped children, 5,000; and for moderately and mildly handicapped adults, 8,000. Our facilities fall far short of these figures and it is common knowledge to many public representatives, apart from members of the medical profession or of local authorities, that there are children living at home who should in fact be in institutions, who are in need of care and of expert help which they are not getting at present.
How are these services to be organised? Voluntary organisations—and by that term, I mean the lay as well as the religious organisations—have, with one exception, been responsible for providing facilities for the mentally handicapped in this country. Only one health authority has in fact provided a service, and an excellent service it is. Apart from that, all the services either in the form of residential care, or in the form of day-centres, or five-day residential centres, have been supplied by the voluntary organisations. We have got to face the fact that the provision of services for the mentally handicapped will require active co-operation between the State and the voluntary organisations, that the voluntary organisations without the assistance of the State cannot provide them. We must also realise that the State must provide the services in areas where the voluntary organisations do not do so.
This is an important principle which we must accept and it is one which the Minister's Department and the Minister's predecessor have not accepted up to the present. In the memorandum which the Department sent to the Select Committee, dated September, 1962, it was stated in paragraph 31:
As indicated at paragraph 22 all the institutions caring for the mentally handicapped are run by voluntary organisations. This has been found to be a satisfactory arrangement and while there is no legal barrier to prevent a particular health authority from setting up an institution of its own for the mentally handicapped, the Department would favour an extension of the activities of the voluntary organisations.
It was clear from this that the health authorities were not going to build institutions. This is a principle which we cannot accept. This is not an area where we should get into matters of principle and talk about the value of voluntary organisations and the iniquities of State institutions. What is involved is a question of a partnership between voluntary organisations, doing excellent work, on the one hand, and the State, on the other. There is an obligation on the State to provide the services where the voluntary organisations cannot do so. If in fact this view that was expressed to the Select Committee prevails, we will not get the expansion of the services which the Commission so clearly indicated was necessary.
Part of the difficulty of providing the services for the mentally handicapped has been the considerable diffusion of responsibility for this problem. Is this a health problem? Is it an educational problem? Is it a problem of social welfare? The White Paper produced by the Department entitled The Problem of the Mentally Handicapped indicated this disparity of view as to whose responsibility the provision of services was. At paragraph 16, after referring to day-centres for ineducatable children, it states:
Because of the type of service they provide, these last-mentioned enterprises, providing centres on the basis of attendance for portion of the day, do not clearly fall within the ambit of the functions of the Minister for Health. Neither could they be said to be educational establishments and, as such, to come within the responsibility of the Minister for Education. It could tenably be argued that, as the centres provide care for mentally handicapped children many of whom cannot be educated or trained, and thereby provide relief for the parents of the children, they should be considered the concern of the Minister for Social Welfare. The Minister for Health has, however, accepted responsibility (under the Ministers and Secretaries Acts) for somewhat similar groups such as senile and infirm persons and unmarried mothers and their children; it might, therefore, be appropriate for that Minister likewise to accept responsibility (ministerial) for these day-centres on the grounds that they fall more nearly within the ambit of his functions than elsewhere.
But this lack of responsibility is not just merely an academic point to be made in a debate; it works in real life in the services not being provided because in fact persons connected with the voluntary organisations know full well what happens.
They know that you negotiate with the Department of Education for your teachers' salaries and for the provision of teachers and for the transport costs, and you negotiate with the Department of Education for the building costs of a new school or the repair costs of an existing school. You are then concerned with the Board of Works for the planning. You go on the next part of your rounds to get help through the local authority or to get assistance in the way of the medical or nursing staff involved. In Dublin, you deal with Dublin Corporation for school meals. In fact, a great amount of time, talking in terms of years, has elapsed before these negotiations bear fruit. I do not want anything I say to be regarded as any reflection on public officials who have to deal with these problems because I think it is the general experience that nothing but understanding and sympathy is obtained from these public officials, both in local authority and Government Departments, who are concerned with this problem. But the fact is that the whole system is such as to bring about delays which are unnecessary and which, in fact, result in the provision of services being so long delayed that in some instances they are not supplied at all.
We made reference to the problem of sheltered workshops. They have in Cork an excellent sheltered workshop started by a local organisation. What authority in Dublin is responsible for the provision of sheltered workshops? Is it the health authority, the Department of Education? The Department of Health cannot do it. Is it Social Welfare? Nobody takes responsibility, and the sheltered workshops are not put up. If, in fact, the local associations concerned with this problem set out to do something, they do not know which Department to go to.
This brings me to what I believe to be a very necessary reform in our whole setup in regard to mental handicap. We in Fine Gael believe there should be established a special statutory body charged with the responsibility of providing, or alternatively seeing to the provision of services for the mentally handicapped. Such a statutory body would co-ordinate the existing services: it would avoid the administrative delays that exist at present. It would establish services in areas where voluntary organisations at present are unable to do so. The Commission in its report indicated the necessity for co-ordination and suggested that an institution for the mentally handicapped be established. It seems to me it should have gone farther and that what we need is a statutory authority responsible for the provision of services because the present setup and the diffusion of responsibility between health authorities, the Department of Health, the Department of Education and the Board of Works, with the Minister for Finance behind them all, means that services are not now being provided.
Such an authority would not, in fact, usurp the powers of voluntary organisation, either clerical or lay. It would work as health authorities work at present and provide the services which it is statutorily obliged to provide through the medium of voluntary organisations where they exist and build institutions where they are needed and do not exist. Until this whole situation is rationalised, we shall not get the progress which is needed.
On the subject of mental illness generally, the Minister's predecessor last year described it as one of the most pressing health problems we had. There are over 19,000 people in our mental hospitals. We need better accommodation and more out-patient clinics. The present staffs of out-patient clinics that do exist are grossly overworked and the clinics are understaffed and overcrowded in practice. We need more trained psychiatric workers. This is a matter we have referred to in considerable detail in our policy document. There are only two people in the country with a PSW qualification compared with 30 in Northern Ireland. Undoubtedly the trained psychiatric social worker would help, to a significant degree, in getting over the grossly overcrowded conditions that exist at present.
We have a record in respect of mental illness of one of the highest ratios in the whole of Europe per 1,000 of our population in mental homes. A great many people are in mental homes who should not be there and it is partly because we have not got out-patient clinics and partly because we have not got trained PSWs. These workers are, in fact, able to prepare families for the return of the patient, prepare the patient himself when his illness is cured or almost cured, and also able to prevent breakdowns when the patient has left hospital. This is one cause of the deplorably high number of people in our institutions.
There are areas for reform in practically all aspects of the Minister's Department and none more glaring than in the area of physical disablement. Under the regulations at present, the health authorities have power to pay maintenance allowances for persons undergoing training for vocational rehabilitation. The present weekly rate is totally inadequate but apart from that, there is a rigid means test. What happens to a disabled person who has to undergo rehabilitation training in an institution is that his social welfare payment is taken into account in deciding the amount of the maintenance allowance paid to him. In fact, it ends up that a person who may have got a serious injury in an industrial accident and may at the same time be getting social welfare insurance, instead of getting £4 per week—the maximum under the regulations—ends up by getting £4 17s. 6d. on top of the social welfare payment.
More serious still, is the lack of uniformity in the standard of rejections on medical grounds. In fact, throughout the country very different standards are applied to determine whether a person should get the maintenance allowance and undergo the training which is available. One of the serious aspects of this problem is the long delay involved. It can take from four to six months, for a person who perhaps has had a disabling disease or perhaps an industrial accident and is fit for rehabilitation from the medical point of view, before he is declared entitled to the maintenance allowance. I know of cases of people who had to stay in hospital at an extraordinarily high expense to the State because of the long delays involved in getting them a maintenance allowance. There is a training fee under the Disabled Persons Rehabilitation Regulations of £4 a month which is completely inadequate and which I trust will be increased when the increases referred to in the Budget come to be implemented.
We have already referred earlier in the debate to the position of people in receipt of disablement allowances and have indicated our determination to see that people will not have to suffer a reduction in disablement allowances, or home assistance as the case may be, merely because they get an increase in the social welfare allowance. The Minister's predecessor did not agree with this point of view. On 29th January of last year he expressed the view in the Dáil that he was against giving double increases to persons and was against giving them an increase in their disablement allowance as well as an increase in social welfare allowance. That is bad logic, apart from being a very poor form of charity. It seems to me that if a person is entitled to a social welfare allowance and also to a disablement allowance because of serious disablement, in fact, there should be no reduction because of the increases in the social welfare code.
In this area of rehabilitation it seems to me that there is great need for more decentralisation. There are, of course, certain types of rehabilitation, such as the care of paraplegics, which do need a central organisation but it seems to me that there could be developed to a much greater extent rehabilitation centres on a regional basis attached to the large hospitals throughout the country. We should also develop in this country a scheme for the homebound, disabled persons who are at home, unable to go out but who can, in fact, work in their home and lead useful lives. Such schemes are being operated in other countries such as Denmark but are unknown in this country. They could, in fact, be developed in association with the domiciliary welfare service which we have proposed.
The Minister should seriously consider the establishment of a national register of disabled persons. That would facilitate assessment of disabled persons and would also facilitate their placement in employment. In this connection it seems to me that we have got an obligation to endeavour to educate employers. Many employers, of course, are very alive to the desirability of helping disabled persons and many employers give employment to disabled persons, but not all. I know of one case of an employer who had, in fact, employed a disabled person, a mentally handicapped girl, and, when the 12 per cent increase in wages came, the girl's father was sent for and, instead of being told that she was to be given an increase in her small weekly wage, he was told that her wage was going to be reduced because costs had gone up. It would be a source of scandal if I were to give the name of this particular employer and I shall not do so but, in fact, this has happened. It seems to me that we have got to educate employers to their responsibilities in this connection.
It is now generally recognised that the necessity for a hospital building programme is on a very vast scale. It is sometimes thought that we have enough hospital beds in this country and people who are inclined to indulge too much in the Guinness book of records and other forms of statistics are inclined to be misled by the fact that we have so many hospital beds per thousand of the population. These statistics cloak the reality and there is great need for a very considerable drive for more hospital accommodation, improvements in county homes, the improvement of mental institutions and the improvement of general hospitals, maternity hospitals and the institutions for the mentally handicapped.
This, unfortunately, was not the view of the Government. It was, unfortunately, not the view of the Government in its First Economic Programme because the First Economic Programme stated that social investment in the past had given us an infrastructure of housing, hospitals, communications, et cetera, which is equal, in some respects, perhaps, superior, to that of comparable countries, and it was suggested that social needs would soon be overcome.
We have criticised this view in the realm of housing and we have pointed out how wrong it was and we have pointed out that the Government acted on it and that there was a decline in housing. It happened also in the sphere of hospitalisation and if we have a big backlog in the sphere of hospitalisation now it is because the Government took this view in its first economic programme and carried it out. In spite of what was said in the first economic programme the Minister's predecessor, last year, in the course of his introductory remarks, at column 135, Volume 127, said:
To achieve a final solution to our hospital problems in the matter of physical accommodation will entail staggering financial outlay beyond our immediate resources.
In 1964, it was recognised that we had a staggering outlay to face in respect of our hospitalisation programme and yet the programme, of course, was permitted to decline under the first economic programme and this resulted in the very serious situation which we have in so many new fields of health, physical and mental, throughout the country.
I should like to join in the tribute which the Minister paid to the late Noel Burke and to express on behalf of us on this side of the House our very deep gratitude for the many years of work which he did on the Voluntary Health Insurance Board, in the National Organisation for Rehabilitation and many other fields of public service in which he gave so unstintingly. I do not think it is exaggeration to say he lost his life because of the work he did for the public good and we should extend to his widow and family our very deep regrets.
The Minister, as I have said at the outset, has got now the task of preparing for improvements and reforms in our health services. We believe that these reforms are necessary. We believe that radical reforms are necessary. We sincerely hope that the Minister will not adopt the attitude of his predecessor, will not pretend to this House and to the country that he is interested in reform and stifle any efforts at reform in the way he did.
I believe, looking back on it now, that Fine Gael took a wrong decision in deciding to work on the Health Services Committee. With the benefit of hindsight, it is now possible to see that the Health Services Committee was a front to do nothing, to hide inactivity and that we would have been better off making known to the public our views, views which we proclaimed again in the course of the last general election. It is past history now. We are going to continue to press our views. It was not without cost, let it be said, because the propaganda against us was to my own knowledge successful. A canvasser in my constituency was put out of a house because, he was told, they were against a Party in favour of socialist medicine. Another canvasser was told that Fine Gael were Communists and to go about his business. The propaganda against us was not without success. As I have said, we are prepared to forget the criticisms that were made, prepared to forget the line that was taken against our proposals for a national health insurance scheme, if, in fact, the Minister is prepared to adopt it. If he does, he will have our whole-hearted co-operation and all our people will benefit from it.
