Skip to main content
Normal View

Dáil Éireann debate -
Wednesday, 2 Mar 1966

Vol. 221 No. 5

Committee on Finance. - Vote 48—Health (Resumed).

Debate resumed on the following motion:
That a sum not exceeding £17,337,000 be granted to defray the charge which will come in course of payment during the year ending on 31st day of March, 1967, for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain Services administered by that Office, including Grants to Local Authorities, miscellaneous Grants
and a Grant in Aid.—(Minister for Health).

As I was saying last night, this is one of the most intimate services provided by the State. It concerns the lives of the people very closely as there are very few people who do not at some time have recourse to a doctor. In the past 12 months the present Minister has tried to do more to make it easier to obtain treatment. I referred last night to the choice of doctor and choice of hospital now provided. This is the greatest advance that has been made in our time because under the old poor law system, the red ticket, the dispensary and everything connected with it, bore the stigma of poverty and even after the Health Acts of 1947 and 1953, we still had the old problem. Although we had highly qualified doctors, and none of them appointed unless he was highly qualified, the dispensary system was still there as our fathers and grandfathers knew it. The Minister was very wise in changing that position. In certain parts of the country he may not be able to abolish it altogether but where it can be done, it is being done. We all realise the independence it gives to a citizen to be able to go to the doctor or hospital of his choice instead of going to the dispensary. We are very pleased about this. Every member of a health authority and every public representative, irrespective of Party, welcomes this big advance.

Deputy Fitzpatrick yesterday suggested we should have completely free treatment and that the White Paper did not go far enough.

(Cavan): Not free treatment, but treatment under a social insurance scheme.

The Deputy felt the proposals did not go far enough. I agree with him that if the State could afford it, I would like to see us going the whole way——

What do you mean by that?

Giving it to a man free, but we have not attained that stage here.

That is the Russian system you want.

No, but if we could do more for people and if our resources allowed it, I should be glad of it. The Christian way is to let anybody pay who is able to do so. I am a member of the Voluntary Health Insurance Scheme and I was delighted I had joined when I got pneumonia in 1961. It stood by me very well at that time. It costs me about £25 per year and it is cheap at that.

(Cavan): Surely the Deputy did not go into hospital with pneumonia?

If I had the able advice of the Deputy then, I might have been sent to some place that he would like to send me.

(Cavan): The Deputy should have been treated at home.

I did not ask for the Deputy's advice then and I do not ask for it now. His tune yesterday was: "Anything you can do we can do better". Under their social insurance scheme, he said they were going to give us all these things but the Deputy knows that when it was possible for his Party to do these great deeds, they did not do them. It is all very well to say: "We will back the Minister in all the advances he is making", but I asked the Deputy last night if he would back the Minister if he decided that we should raise money by taxation. Would he go into the lobby in support of the Minister in doing something like that?

(Cavan): I told the Deputy that if I was run out of America, I would not go to Germany for money.

I must say that is a rather cheap jibe and not worthy of the Deputy. The only difference between the Deputy's Party and ours is that we are standing up to our responsibilities. In 1957 the Deputy's Party ran away from their responsibilities and left somebody else to do the dirty work.

(Cavan): The Deputy's Party is running around the world looking for money.

Do not draw me any further because my memory is reasonably good. I should prefer to carry on with this most charitable document before me which is doing something for the people. I did not interrupt Deputy Fitzpatrick and I asked him only one question when he was finished. He can ask me questions when I am finished.

In regard to the regional boards, we have a regional board in the Dublin Health Authority made up of the city of Dublin, Dublin County and Dún Laoghaire Borough, and I consider that this board has done a reasonably good job. We are responsible for quite a number of hospitals and for the general health of, one could say, nearly a quarter of the country's population. Naturally the board suffered from growing pains when it was set up but I am in agreement with the regional board idea. We had experience previously in County Dublin of not being able to get ambulances except at the will of the then Dublin Board of Assistance and the service was very poor. We have a regional ambulance committee now and the Dublin Fire Brigade ambulances will cater for the city and county, and Dún Laoghaire also has an ambulance. We have tried to bring our ambulance services up to date and to ensure that they can be called on quickly. We have done all this under the regional scheme and we have succeeded very well.

In regard to the hospitals, one thing which we are up against is a shortage of beds. One reason for this is the number of old people who are going into hospital and being left there by their relatives and friends. We have reached the stage when we will have to give some encouragement to the relatives and friends of old people to keep the old people at home. I know that we have a scheme under the 1953 Act and even under the 1947 Act to allow so much to a sick relative at home but the yardstick is the means test. I know that a scheme to provide for old people would cost a great deal but it would be a good thing if we could have a system under which relatives could be allowed so much for keeping their old people at home, or even that a stranger looking after an old person would be allowed so much. Such a scheme would relieve overcrowding in hospitals. The Connolly Memorial Hospital was built solely for tuberculosis patients and thank God, the day has come when we have a number of idle wings in that hospital used now for geriatric treatment. In St. Mary's Hospital in the Park, which was also a sanatorium, we also have a number of old people now. The same applies to Crooksling Sanatorium. We also have old people in Cork Street. How to get over this problem of old people is something to which we have given very serious consideration at our various meetings and on our visitations to the various hospitals. It is one of our big problems. It is also a very expensive problem, trying to get space for these people, and it is costing the Department of Health and the ratepayers quite a lot of money.

I heard Deputy Tully talking about old people last night and he said that when a husband and wife went into one of these places, they were immediately separated. The Little Sisters of the Poor in Roebuck have a system under which the husband and wife can stay together but this scheme is only in its infancy. I should like to take this opportunity of paying tribute to the Little Sisters for the wonderful work they are doing. However, it is all right to say that one, or two, or three organisations are doing this but it is impossible to deal with this problem on a wide scale and some financial encouragement will have to be given. It is a huge problem, one of the big problems of our time. I know as a member of Dublin Health Authority that we have a waiting list for St. Kevin's of old people who are trying to get accommodation.

(Cavan): There is something about that in the White Paper.

I know there is. I am dealing with the White Paper and giving my own observations on what we are up against. It is a big advance. While the——

Relevancy is not always the Deputy's strong point.

I am just giving a résumé of our experience. We also have the Red Cross Society and the various charitable organisations which are trying to do something worthwhile. I am a member of the Housing Committee of Dublin Corporation and we have built houses for old people. We have a number of flats left for them, so many rooms for them, along with the younger people, and we are putting——

I am sorry to interrupt the Deputy, but where in Dublin did they build houses for the old people?

We have some in Dominick Street——

——and some in Botanic Avenue.

I mean flats. Did I say houses? In any housing scheme we have, we are trying to get in a number of old people because we feel they will be looked after by the younger people in the flats. We have had a very happy experience in regard to old people's flats in Botanic Avenue, Glasnevin. These are the matters that concern us all and we are anxious to do our best to help in that regard. I welcome the suggestion by the Minister in his White Paper. In his speeches he has featured the aged more than any other section and, as a member of a local authority up to the time he became a Minister, he knows the problems and what we have been up against.

The provision of drugs for the middle-income group is a great advance. One of the things that greatly concern us is that people who have to go to a doctor may have to pay his fee, which may only be a nominal one, but it is the expensive drugs that are really the burden on them. I congratulate the Minister on introducing that provision. It is a definite advance. The abolition of the joint family income is another advance. We have had a case of a road worker whose father, an old age pensioner, had to go to hospital and the son was called on to pay for him in hospital, to pay money for him that he had not got. I am also pleased by the abolition of the 2/6 and 7/6 charges respectively when a patient goes to a voluntary hospital. Very frequently such people do not have the money with them because of their illness and they have to go out again. This is a great charitable advance which is being made by the Minister.

I want to refer to the big programme the Minister has set himself with regard to the voluntary hospitals. I would like to see him with millions of money at his disposal and he would then be able to make a great job of the old hospitals we have. We have three mental hospitals under the Dublin Health Authority. One of them, St. Loman's, is an up-to-date hotel due to the efforts of the medical officers, the health authority and the Department of Health. I want to pay a tribute to the Minister and the officials of his Department for that. Through their efforts they have made St. Loman's one of the most up-to-date hospitals in Europe.

The two other mental hospitals are St. Brendan's and St. Ita's and in these we are up against the problem of overcrowding. This is one of our great problems in dealing with mental disease and the first advance that can be made is to relieve overcrowding. Advances made in the treatment of mental illness over the last few years have been wonderful but overcrowding is still the problem and I am pleased the Minister has dealt with this matter in his White Paper.

The problem of our young retarded children is also a big one and it concerns all of us. The Dublin Health Authority has set up treatment centres in St. Loman's and St. Ita's for the treatment of young children but we have a long way to go yet. A number of the religious hospitals have day schools in the city of Dublin and the Sisters of Charity, the Brothers of St. John of God and others are doing great work. The Minister has taken a great interest in this problem and has made great advances in dealing with it but the training of personnel is a problem in itself. It is surprising the large number that are seeking admission to these hospitals.

The Minister has another problem. I am on the boards of quite a few voluntary hospitals and I know that the big difficulty today is that of dealing with heavy overdrafts. The current deficit has always been paid and will continue to be paid by the Hospitals Commission on the advice of the Minister but, even at that, there is always the question of expenditure and overdrafts mounting up and the banks urging the boards to keep them down. The old private hospitals are a problem both for the boards and for the Minister and I want to thank him for the manner in which he has treated representations made by me on behalf of certain voluntary hospitals with which I have been associated over the years.

The estimated total value of work to be done on the voluntary hospitals is £6,815,000 and the amount for local authority hospitals is £5,186,000. We can see the huge problem facing the Minister and the various local authorities in this matter. The value of voluntary hospital work in progress at the moment is £345,000 and the value of local authority work on hospitals is £2,500,000. No matter how we look at it, we have a big time lag to get over. It is wrong to think we can do it overnight. However, if we succeed in improving the health of our people, giving them a chance of modern treatment in first-class hospitals, we will have achieved something.

The Minister referred to means tests. I submit that the means test has created injustices. We have in the country about 300,000 people suffering from rheumatics of one kind of another. These diseases are not within the notifiable disablement classes and do not qualify for allowances. If they did, many people now occupying hospital beds at great expense to the State could be looked after at home by relatives. This is a big problem and I do not look for too much for a start. I suggest that the Minister should make a survey to find if he can make a worthwhile beginning. If he could succeed in giving allowances to such people he would relieve the hospitals and the State of considerable expense.

The White Paper is a very enlightened document which makes provision for a lot of the things all of us would like to see in improved health services. We cannot look on ourselves as a highly industrialised country.

Statements have been made about our farmers. It has been said that farmers under a certain valuation should be given free treatment. I should like to point out that under the 1953 Act certain discretionary powers were permitted in respect of white collar workers and farmers. I had experience only three years ago of a young man with five or six children who got a stroke and spent several months in hospital. He had £2,000 a year as a traveller, but being young did not make provision for his family. The discretionary clause in the 1953 Act made it possible for us to bring his case to the attention of the CEO.

I suggest that in any future improvements of the health services, no matter what yardstick we adopt, this discretionary power, which has done so much good in the past, should be retained. If it is not we could be depriving wives and families of sick bread winners of the necessaries of life. Senator Fitzpatrick of Cavan spoke of insured workers as if we were a highly industrialised nation. I should like to point out that the majority of our small farmers are self-employed people.

(Cavan): The small farmer is free up to £15.

The Deputy implied that one section would be free from social insurance contributions. I do not wish to enter into a discussion.

(Cavan): The question can be answered simply. Those in receipt of social welfare benefits would be free. Small farmers up to £15 valuation would not have to pay contributions.

The 1947 Act did a lot of good. The allowances given under it in respect of tuberculosis patients, not only relieved people of worry but it got people to enter hospital much earlier. I agree that advances in medical science also improved but the 1947 Act contributed considerably to the curbing of TB. Another big problem is the training for employment of disabled persons. The Minister recently visited the Rehabilitation Centre and he refers to the problem in the White Paper.

I have reviewed in a general way the health and associated problems we are up against. A total of 29.2 per cent of the population are receiving free treatment. The Minister has ensured that in future those in the lower and middle-income group will not be harassed for a medical card as they were in the past. That is a big advance and I take this opportunity of congratulating the Minister on doing so much in a short time. I hope prosperity will come his way and that he will be able to finish the job he started.

Most of this debate has related to the White Paper. I should like to make a few comments on things the Minister could do without waiting for the implementation of the White Paper which at the earliest will be the end of 1967. I understood the Minister to say, when I was watching him on television, that it could only be operative then if the money was available. For that reason I should like, first, to refer very briefly to the geriatric problem. The Minister stated in his opening speech that our upper age group is high. It is high in proportion to other countries and it is likely to grow. The national conscience has been to some extent aroused with regard to this problem. In many centres geriatric committees are being formed. The problem varies from place to place, from big town to small town and from town to rural district. The problems faced in relation to this situation can be met better by a local committee.

The major difficulty in regard to old people is to get somebody to look after them. Then, if there is nobody to look after them, they are extremely lonely and ultimately end up in a public institution. That public institution is costing the State a great deal more than if it were contributing something towards the maintenance of those people in a home. For that reason the Minister, without waiting for the implementation of the White Paper, should concentrate on the fact that something should be done immediately in relation to this problem. He should give these local committees—charitable people who have come voluntarily together—every aid possible. Indeed, this applies to many facets of the White Paper. There are many things that could be implemented sooner. After all, the White Paper is only a general direction on health for the future. With some portions of it, we will agree, and with others, we will not.

If the Minister is going to create a new background to our medical services, he is faced with a problem highlighted yesterday by Deputy Fitzpatrick. There is in existence a contract between dispensary doctors and local authorities. As far as I know, that is a contract for employment at a definite salary to be continued until such period as they reach retiring age or choose to retire themselves, and subsequently they are entitled to a pension. I do not see how it is going to be possible to wipe out the whole dispensary system, which is the only way I can interpret the White Paper. There are 545 dispensary doctors in the country. Only 70 of those are in Dublin, the biggest centre. If the Minister hopes to create a health service, he has first to get the fullest co-operation of the medical profession in running that service. There is no chance of running it without that cooperation. That has been proved by what has happened in other countries.

I just want to cite two instances. At present the service in the United Kingdom, although it may be satisfactory from the point of view of some people, is obviously not satisfactory to the medical profession. English doctors are emigrating, and were it not for the outflow of doctors from this country, they would not be able to maintain the service. In the past few years the situation has become more critical and they have had to fall back on overseas doctors. In a great many of the hospitals, in private practice and in other branches of the profession, the service is being carried out by coloured doctors. To draw the parallel, there is disagreement between the doctors and the Government in running the medical service in Belgium. As the Minister probably knows, the Belgian Government are being brought down by this disagreement. The doctors were dissatisfied with the conditions obtaining there.

I would like the Minister to bear that clearly in mind. Possibly in his case I may be pushing an open door, since he has indicated he is willing to discuss with all concerned the best means of setting up a health service. As I say, there are 545 dispensary doctors, all of whom are pretty contented with the conditions that prevail at present. It is only in recent years they have had satisfactory conditions. About 25 years ago a dispensary doctor was paid about £100 a year and expected to run a car, keep up appearances, exist on that and educate a family. Today their conditions are better. When they have an established and secure service, they will not give it up easily without some form of resistance unless they are guaranteed that other conditions will prevail that will equate to what they are getting at present. So much for the 545 dispensary doctors, many of whom are in outlying districts and are the only doctors in the area.

There are also approximately 600 private doctors practising in Ireland. The great majority of them are in Dublin, Cork, Limerick and Waterford. Different conditions prevail there from those in other parts. In the bigger rural towns, you may find two or three private practitioners and in the smaller towns, you invariably find one. That is the body politic of the medical profession the Minister will have to satisfy. That is not as easy as it seems. The trouble with all medical schemes is that a lot of people get together in a closed office with statistics and formulate plans which look grand on paper. I am sure everybody wants a medical service which will improve the lot of the patients and at the same time, satisfy the medical profession. There are in Dublin people who have built up private practices and gone to considerable expense. Through their ability they have established quite a reasonable practice. Some of them have expanded and are even in a position to take assistants.

As I read the White Paper, doctors are to be limited to a certain number of patients. Apparently, somebody with a terrific statistical brain in the Custom House or elsewhere worked out that 2,000 patients were the maximum any doctor could have. That is not a factual way of approaching the situation. If we are to approach it from that angle, I cannot help feeling that those people concerned in relation to these health services are thinking entirely of a capitation fee. I do not think a capitation fee will be a satisfactory basis. That was tried in the United Kingdom under the old panel system and it was abolished as unsatisfactory.

Mr. O'Malley

It was abolished?

The old panel system does not exist any more. It was changed.

Mr. O'Malley

It does not exist? Capitation?

There are certain degrees of capitation but the system today is not the same as the earlier system. I speak subject to correction. Perhaps the Minister has more recent information at his disposal, but I know that there has been a considerable change in the British medical services. What they have now is almost a free-for-all medical service but, wealthy and all as they are, they are unable to pay for it and they have had to change the system considerably. At the moment it is very involved and it is a system they probably will not be able to continue because they have not got the doctors.

Leaving the British out of the picture for the moment, what I should like is a medical service satisfactory to both the patient and the doctor. The Minister will get, I think, the fullest cooperation from the medical profession, and I think this is what the ordinary patient would like, on a contractual basis. That can be done through voluntary insurance. That is one way. Voluntary insurance has the great advantage that it brings a wide group into the general practitioner service. There seems to be a widespread idea that most people can afford to pay quite easily for a general practitioner service. People employed by the State are in a happy position in that, if they go out sick, they will enjoy their salaries for a certain period. The same is true of Deputies; they get their allowances. The position is different in the case of the self-employed.

These are the people who have difficulty if they suffer long illnesses. If they get pneumonia, like Deputy Burke, and suffer a relapse, they may be ill for 12 or 14 weeks. During that period they will be earning nothing. That is a tremendous hardship. These patients would be under treatment from general practitioners and there is nothing in the Minister's proposals to meet these cases. That is why I say there should be a contract and, if there is a contract between the doctor and the patient, one will get better results. That system is being successfully operated in other countries. Under that system there is a choice of doctor. Naturally a patient will go to the doctor he believes will give him the best service and, if it is on a contractual basis, the doctor will collect his fee. If the Minister accepts the Fine Gael social insurance policy, the fee will be paid through that medium.

I want to see a contract between the patient and the doctor rather than between the Custom House and the doctor because the former will achieve a better result. The Minister and his officials may not be aware that a great number of people, who are entitled to free treatment, prefer to go to a private doctor in the case of a short illness, even though paying for treatment may constitute a hardship on them. I should like people to be in the position of being able to go to a private doctor without being under any compliment to anybody. The contract would be between them and the respective doctors, and the doctors would be paid. If the Minister takes a poll, he will find that 90 per cent would prefer to have a choice of doctor. That is being afforded here, on paper anyway. That is why I suggest the Minister should lean towards the capitation system as much as possible. Otherwise I do not think the system will be a successful one. It will be a contract between the Custom House and the doctor. But there is no reason why we should not do through insurance what is done in other countries. An insurance corporation controls all the finances and, for those in the lower income group, the State pays the contribution in its entirety. After that, there is a sliding scale according to capacity to pay. If the Minister studies that in conjunction with his advisers, he will find he can devise a system worthy of the country and suited to it.

With regard to choice of doctor, it is all very well to offer a choice on paper, but really there can be no choice except in certain centres of population, such as Cork, Dublin, Limerick, Waterford, Wexford, Kilkenny and a few big towns. I know rural Ireland fairly well. I have spent numerous holidays in Donegal and in the west. In the outlying areas there is usually only one doctor. Here the question of the dispensary doctor arises. What will the Minister do with him? Will he say that he is no longer required and his contract is broken? I should imagine he would have a great many High Court actions on his hands and it would cost him as much to defend them as it would cost the doctors to bring them.

Mr. O'Malley

I should tell the Deputy that the Irish Medical Association and the Medical Union are in process of having discussions with my officials and myself with regard to safeguarding the position of dispensary doctors and finding out what is the best system in order to ensure an equitable and just decision being arrived at. I am satisfied that, with co-operation and goodwill, we will come up with a solution. These discussions are taking place at the moment and many of the points made by the Deputy have already been made by the very competent representatives of the professional bodies.

The Minister is a little sensitive. I am only giving my opinion.

Mr. O'Malley

I am only telling the Deputy what is happening.

I am expressing a point of view and I am entitled to that view on two grounds: first of all, I am a doctor, though not a practising one now. I was in private practice all my life and I have some idea of what a choice of doctor means to people. There are places in which there is no choice and there never will be any choice.

Mr. O'Malley

That is true.

The Minister's White Paper is, therefore, badly worded. I think it is in paragraph 44 the Minister says the dispensary system will disappear. That, of course, is nonsense. It will not disappear. The White Paper says the dispensary system served us well for a hundred years and anybody who eradicates that system will, I say, do a disservice to the health of the nation as a whole. The White Paper also sets out that the dispensing of drugs, where possible, will be done through the chemists. That is a very good idea. It is long overdue.

Mr. O'Malley

Would the Deputy mind reading the first few lines of paragraph 45 in page 32?

It says: "It is recognised that on the discontinuance of the dispensary system, special steps would be necessary to retain doctors to provide a service in some of the more remote areas and allowances to supplement the standard payments would be offered to doctors in such areas."

(Cavan): That is another way of saying the service will be continued where necessary.

It does not get away from the fact that it will be discontinued in other cases.

Mr. O'Malley

We are in the process of doing that. The main thing is that the principle has been accepted by everybody in the country that the dispensary system in Ireland is a bad one.

Is that the reason that dispensary doctors are being appointed on a temporary basis?

Mr. O'Malley

That is right.

Have the doctors accepted that it is a bad system?

Mr. O'Malley

The Irish Medical Association agrees with the idea of offering the patient a choice of doctor. The only point on which we differ is as to how compensation will be given or how they will be paid in future and how their new areas will be scheduled; in other words, what the future will hold for doctors. The doctors' future will be this: No man, as a result of any action of the Houses of the Oireachtas will be in a worse position than he was in hitherto. It is my belief that many of them will be much better off.

(Cavan): The Minister accepts that he has contracts with doctors and that he can only be relieved from these contracts if the doctors are satisfied?

Mr. O'Malley

I do not wish to go into any fine distinctions or legal niceties. I wish to be just and equitable. I do not want to catch anyone out by saying: "I have a contract with you", or "I have no contract with you" I intend to do certain things, and we will be fair with these people who have, in the main, done trojan work down the years in very difficult and adverse conditions in certain areas of Ireland. We would never have been able to carry out the dispensary services were it not for the heroic work done by the dispensary doctors and the midwives.

I am not attacking the dispensary doctor. I have been standing up for him. However, that does not get away from the fact that the Minister proposes to abolish dispensary doctors. Those are his own words. I am pointing out to the Minister that if he is going to abolish dispensary doctors, he will have to replace them by something better.

Mr. O'Malley

You are not going to wake up on a Monday morning to find all the dispensary doctors gone. There will be a transitional period.

The Minister is much too sensitive. I think I have been very kind to him. I have been praising some of his proposals.

Mr. O'Malley

As the Deputy says, he is a doctor and he is not practising; I am a civil engineer and I am not very civil at times.

As the Minister has had his say, perhaps I will be allowed to continue. I had left the matter of the doctors because it is a rather sore point. I was actually agreeing with the Minister when he intervened a second time. Regarding the chemists, I do not know whether the Minister is aware that 60 chemists have gone out of production, shall we say. There are 60 fewer chemists in the State than there were, owing to the fact that a great deal of their work has been taken over by the State. I seem to be the champion of everybody in the House today. Let me say this for the chemists: they are supposed to make an enormous profit. It is true the percentage profit of the chemists is fairly high but then the percentage of waste is considerable. If Deputy O'Connell favours a particular drug and prescribes it, the chemist cannot order a small quantity; it has to be ordered in bulk. It may well happen that Deputy O'Connell thinks the drug is not all he thought it was and may discontinue prescribing it, and the chemist is left with it. Although the percentage charge is high, at the same time, the over-all return has not been good in recent years. The fact that 60 of them have gone out of business in the country as a whole is an indication of the situation, and unless there is a change, more of them may have to go.

The chemist's shop is essential to all of us, even if we only want to buy a tube of toothpaste. The Minister's proposal is a very good one—I am praising him this time and enabling him to become more civil—and it is long overdue. The only rational way to do this is through the chemist. However, there is nothing in the White Paper as to how the Minister proposes to pay the chemists. I presume the chemists will have a contract with the Minister and his Department which makes me feel—perhaps I am too suspicious—that the contract will be with the Custom House.

Mr. O'Malley

It is set out in page 33, paragraph 48, of the White Paper.

Who is going to pay them?

Mr. O'Malley

It reads: "It is, therefore, hoped to negotiate a satisfactory and economical scheme with representatives of the retail pharmaceutical chemists under which prescriptions given by doctors to patients under the service would be dispensed by retail chemists from stocks supplied by the health authority."

The Minister will agree that it is very vague. Will the health authority, or the regional council as it will be, buy the drugs and give them to the chemists?

Mr. O'Malley

It is anticipated that the Combined Purchasing Section of the Department of Local Government will stock up the chemists' shops with the necessary drugs and medicines. At no cost to him, the chemist has the drugs and medicines on his shelves. When a patient gets a prescription from his doctor, he goes to the chemist of his choice. The prescription is dispensed and we will reimburse the chemist with an agreed fee for the prescription. I might also stress that this is somewhat hypothetical. Discussions are still going on. It might well happen that we will never be in a position to come to an agreement with the chemists. I am merely giving the Deputy, as he asks me, an outline of what we have in mind.

I understand. In other words, the chemist is purely a dispenser and nothing else. There is still the same system of buying and distributing drugs. It is the same as before, except that the drugs will be passed to the chemist who will make up the prescriptions at a fee to be agreed between the Minister and the chemists per prescription?

Mr. O'Malley

No. The Deputy is wrong in dismissing this in such a cursory fashion because this decision makes a tremendous difference to the poorer sections of the community. Whereas old and sick people at present are even now queueing outside dispensaries in Ireland, possibly waiting in the rain for long periods for medicine and drugs—and they could also be waiting at dispensaries without being attended to by the dispensary doctor for a couple of days——

That is not my fault. It is the Minister's, if anybody's.

Mr. O'Malley

It is not a question of whose fault it is. The Deputy stated that the system would be the same as it is at present. It is far from that.

The Minister is getting cross again.

Mr. O'Malley

I am not getting cross at all.

(Cavan): I think if Deputy Esmonde were allowed to make his speech, it might be better.

Mr. O'Malley

I was asked a question, but I shall sit here now and I shall not open my mouth.

I did not expect an answer until the Minister was replying but I do not mind——

Mr. O'Malley

Obviously the Deputy does.

We have elicited from the Minister that exactly the same system will prevail in the future as that now operating. It is not a satisfactory system. I had thought that the Minister was going to have a contract with the chemists as a whole to enable anybody who got a prescription from any doctor—there being free choice of doctor and chemist—to take the prescription to the chemist and collect the medicine or tablets. I understood there would be some contract between the chemist and the Minister which would cover that transaction and which would be independent of the patient. Apparently that is not the case. The system is not really being changed at all.

I should like to say a word about blue cards. According to the White Paper, there will be no more trouble with them. The Minister has said that in the White Paper proposals the means test is no longer to apply collectively to the household. I think it should be an established fact that the old age pensioner is entitled to get a card, whether living with some member of the family or not. He was always entitled to a blue card before the 1953 Health Act. As far as I know, it was the 1953 Act which first obliged an old age pensioner to seek a card. That should be cleared up now and there is no reason to wait for the implementation of the White Paper. The Minister can do it very simply. I shall leave it at that.

The Minister should give us some background explanation regarding the limiting of the number of patients each doctor may have. I do not see why any doctor should be restricted as to the number of patients. He should have as many patients as he feels fit and competent to deal with. Neither do I see why any patient should not go to a particular doctor if he wants to do so. If you are giving free choice of doctor, all you have to do is to ensure that you will get a good service and you will get a good service without limiting the number of patients.

The Minister said he is going to have new regional boards and, to my mind, that is a good idea which is long overdue. There has been more trouble in medical matters over the question of sending people to hospital, getting and using ambulances than anything else as a result of the restricted system we have at present whereby every health authority is confined to its own county boundaries. Some of us have intimated, by advice to the Minister, by Parliamentary. Questions and otherwise, that the ambulance system is unsatisfactory. If you are to run a proper ambulance system, you cannot confine it within county limits and for that reason I welcome regional boards. I also welcome them because if you are going to decentralise specialist treatment, as was the original intention of the health services and as is the reasonable thing to do, it is essential to have specialist services available. In our case, with our limited population, and limited number of ratepayers, there is no county able to provide satisfactory specialist services within its own confines. It is a pity the Minister has gone out because nearly everything else I said seemed to make him angry. He is replaced now by the Minister for Industry and Commerce who does not get angry.

I shall tell the Minister that you are pleased with him after all.

As a young Deputy. I have listened carefully to the discussion and to the claims made by members of the Opposition about the implementation of portion of their policy. It is easy to make claims when in their position; it is easy to say that they are the brains behind the advance now being made. I am proud that it is a Minister of my Party who has introduced this advance. I am glad to know also that he has the support of most of the people outside the Dáil because most organisations are in almost complete support of the terms of the White Paper. There has been no great criticism of the White Paper itself here or outside and that is an indication that while it may have some short-comings—it may not go far enough to meet everybody's desires—it is a substantial advance towards a comprehensive system that will give much-needed relief to various sections of the community.

Health is a serious matter and should be so treated. It should be above politics and at no stage made a political issue. All Parties should aim at getting the best possible and try to ensure that their approach to the problems involved is constructive so that the end product of the discussion will be greater aid for the needy sections of the community.

I should like to pay special tribute to a nursing sister who lost her life in the cause of nursing in Ballyfermot last year. One of the Little Sisters of the Assumption who was going on nursing duty in the area lost her life in an accident with a bus. It was unfortunate that such a charming personality, who had brought so much relief to distressed people in the area, should have been lost to the community at such an early age. The Little Sisters, who have done such great work, will find it difficult to replace her.

The choice of doctor has been mentioned by all previous speakers and it is something on which we are all agreed. It will raise the status of a person who has to seek the service from that of a second-class citizen. These people will no longer be identifiable as public assistance cases. They will be able to get the same treatment as those who are able to pay. It is a great step forward and one of which we can be proud. We know that in the past local dispensary patients have lost confidence in doctors and at that stage, where there was no replacement, the loss of confidence, whether justified or not, meant that the progress of the patient was retarded. This happens in politics, in the medical world and in all fields where confidence is lost in an individual, a Party or a government and you must have an additional choice.

There are side problems such as the case of the widow who has lost her family, who had been able to pay her way and then finds herself in need of the dispensary doctor and sometimes is reluctant to seek this service. In such cases it meant that when these people did seek the service, the same bond of sympathy and the same under-standing of the case history was not available. Sometimes a patient's case history is an important issue when a vital decision has to be reached. Where a choice of doctor is available, with no stigma attached, it will mean that people in this group will be able to get the service without being identified in any way as seeking assistance. On that score alone I believe that complete harmony will be achieved between all parties.

If we are to cater for people effectively, we must have a knowledge of the needs to be met and the channels available through which to meet them. These are many and varied. The White Paper gives us an opportunity of thinking, in a comprehensive way, about the health of the nation. As the State is about to improve the lot of the sick and those in need, voluntary organisations, with the State, should carry out a comprehensive survey of the situation as it exists to ensure complete co-ordination between the voluntary organisations and the statutory authorities. The change in circumstances will bring new problems to voluntary organisations and possibly in some cases will widen their field. We know that in the past there have been conflicting reports and opinions which gave no reliable information about where help might most effectively be applied. It is obvious that some type of comprehensive examination is necessary in order to ensure that gaps which are left will be covered, that overlapping which had been in existence will be eliminated, and so that the whole situation will be known. Suggestions and opinions from workers in the field of health and social services are particularly desirable. We all know of cases where members of five or six organisations have all been helping one person while many other people in far worse circumstances have been left completely unaided. Some type of register should be set up, particularly in regard to the older group. This should not be very difficult because we have many facilities and sources available which would provide that information.

The question of drugs for the middle-income group was also mentioned. This is a very serious problem. The position is that a person in the middle-income group who has not got a medical card goes to a private doctor and may find it difficult to pay the doctor. He finds it even more difficult to pay for the drugs. The prescription which he receives may have on it the words "Repeat twice". He gets the first lot of tablets, or whatever it is, and is then unable to afford the repeat does. If the bottle is empty, it does not matter what the label says, as far as the patient is concerned. If drugs were available at little or no cost, it would be a great step forward. This is one of the most important aspects of the present review.

The abolition of the dispensary system is tied up closely with the choice of doctor. The system supplied a need in the past and in some cases it was probably not very effective. The elimination of dispensaries where they can be eliminated will meet with the approval of the vast majority of the people. The question of queuing and of crowded dispensaries, of people standing in the rain, people travelling considerable distances in order to get free medical treatment, have all been mentioned. In some cases the bus fare which people had to pay was far greater than the fee demanded by the doctor living adjacent to them, so that they were really no better off in some cases by passing doctors living near them. In the new situation they will no longer have to travel to the dispensary to be coralled together to get attention. Last night Deputy Tully covered this whole question of the dispensaries adequately.

Regional committees have also been mentioned. I am a member of Dublin Health Authority and I hope that the committees which will be set up in the future will not have the same character as Dublin Health Authority which is a political set-up and in which politics is the vital factor and not the health of the citizen. I hope other committees will not operate under the same strain. I hope the new regional committees will regard the health of the nation as above politics.

In the years I have been a member of this health authority, I know that political matters are of more importance to the members than matters of health. On every occasion on which a member of the authority felt that political advantage could be gained by raising political matters, such matters were raised. I hope the regional committees will be more conscious of the needs and problems of the people. On that score I wish the Minister well and I hope that the new members selected for the health authorities will be better than the previous ones.

I take a deep interest in geriatrics. This falls into several sections, care of the aged at home, care of them in the out-patient departments and long and short-stay in hospitals. At the present St. Mary's is re-designing an existing structure for short-stay patients. That is a desirable proposition and one that could be copied elsewhere with success. It means that where the old people are not in very great need of medical treatment, they can be taken into the hospital for a short stay of six weeks, then returned to their homes for six weeks and brought back again to the hospital for another six weeks. By that system families who have not accommodation get some relief, a larger number of old people will get treatment and no old person will become so ill as to need a long stay.

This short-stay system has been tried elsewhere with complete success. If we can get co-operation from the families, we will have made substantial strides in the advance of geriatrics. The long-stay position has been covered by several speakers. It is a problem and so is that of the home patients and the out-patients. Many of our old people could be treated at home if the Minister could provide some financial inducement to their families to keep them there. In that way much could be done to relieve overcrowding in hospitals and to have harmony in the home. Comprehensive thinking should be brought to bear on this question of allowing old people to remain at home and the Minister should be able to make some financial contribution with this in view.

With that is another problem, that of the provision of a central laundry service. Many people who are looking after old people in their own homes are unable to cope with the problem of soiled linen and a central laundry service from which fresh linen would be available would be a great step forward in this matter of geriatrics. It has been tried on a small scale and with considerable success in some places. The old people staying at home cause many problems such as daily dressings and other matters but it is still desirable that more use should be made of the home for the care of the aged so as to alleviate overcrowding in hospitals.

The majority of elderly people living outside look after themselves. This is an ever-increasing problem for while some manage very satisfactorily, others, widowed and in indifferent health, are very lonely. Voluntary organisations can do, and do, a great deal of work in assisting them but many of them have difficulty with their housework and have no one to call on in an emergency. Such people deteriorate very rapidly when they start to go down. There is also the problem of those who can care for themselves but who are alone and find retirement very lonely. Here again, many voluntary organisations give assistance and advice and bring these people out for drives and to social functions. All these things are necessary and desirable.

One of the big problems of the elderly is the lack of adequate financial means of support. Many old age pensioners who qualify for supplementary allowances fail to apply for reasons of pride or ignorance. We should make every effort to bring to their knowledge the services that are available. A system has been tried elsewhere whereby the local services available are listed and attached to their pension books. By this means these people know where to go and what to do. There is a necessity for a full-time warden service, the members of which would visit these people and make known their problems to organisations from which support could be obtained.

An old person was pushed into a hospital, of the board of which I happen to be a member, by a daughter who had married well. When the time came for the discharge of the patient, they had to send that old person home in an ambulance and when it arrived at the daughter's door, she would not take in the patient. We have quite a substantial number of people who are willing to assist such cases in every possible way. It is necessary to make a comprehensive examination of the work being done by voluntary organisations in Dublin and elsewhere. We have many organisations making excellent contributions who should get far more support financially from local and central authorities. We have, for instance, the Mary Aikenhead Social Sisters and the Little Sisters of the Assumption. They do such great work throughout the city and in the country that there is no need for me to go into their efforts in detail. Most Deputies are aware of the example in the care of the aged set by the Bishop of Ossory. A social services centre has been set up in Kilkenny and there is an extension to Crumlin in Dublin. I am glad to notice the Minister has a special interest in this activity and that he paid a visit to the centre in Dublin. There is a similar institution in Temple Street. Meals on wheels are taken to the aged and there is assistance given in many other ways to such an extent that anything I could say here would fail adequately to describe the great work these people are doing.

Tributes have been paid to the nursing service. It is appreciated that many nurses, after a hard day's work in a hospital, rally to the call of voluntary organisations in the perimeter areas to help in the rehabilitation of old people living in those areas far removed from their old homes and constantly in need of attention. All these voluntary efforts should be more actively assisted by the State, by the local authorities and by the public at large.

The control of drugs was mentioned. The position here is unsatisfactory. One may go to two different doctors suffering from the one complaint and the two doctors will prescribe two different drugs. One may go to four different doctors and have four different drugs prescribed for the one complaint. I hope the Minister will see to it that some definite standard is established in regard to drugs. The attitude of some doctors at the moment serves only to confuse people and, possibly, to sabotage their morale. Some doctors tend to prescribe drugs which are not on the local authority lists. These doctors know that substitutes or drugs of equal value are available but they fail to prescribe them. This demoralises the patient when he feels he is getting only second-rate material, though, of course, sometimes the substitute is far superior.

Recently, I reported to the health authority six different occasions that a drug not stocked was prescribed by a doctor, the doctor knowing full well that the drug was not in stock and the patient, an old age pensioner, bought the drug himself in a chemist's shop because he believed the drug prescribed by the doctor was the best, whereas the substitute the health authority had on their list was equally good. We know that vested interests will be active during the course of the discussions here. The question of drugs, hospitalisation, chemists, doctors and others who may benefit from the advances that are proposed, will be uppermost in the minds of certain people.

We need some co-ordination of thought and design in relation to the availability of hospital beds. It is a fact sometimes that we have hospitals with beds and no patients and hospitals with patients and no beds. It is a situation that exists and must be tackled. In Dublin at the moment we have hospitals where there are substantial numbers of beds available while other hospitals are overcrowded. New and clear thinking will have to be brought to bear on the situation so that all available space will be utilised and overcrowding, as far as possible, eliminated. The location and the design of our hospitals will have to be considered.

We appreciate that the Minister has the interests of the nurses at heart. In this respect one section deserves particular attention. I refer to the nurses who specialise in geriatric nursing, which is very depressing for young nurses. In conclusion, I should like to say as a new Deputy that I am proud it is our Minister for Health who is introducing the White Paper that will eventually produce a great step forward in our health services. I appreciate his determination, his activity and his interest in the past in all matters relating to the health of the nation. He has the admiration of the people inside and outside the House. When the final product is forthcoming, I am sure we will all be proud of it and that the Parties opposite will have reason to feel proud of their contribution. I suggest that in this context there is no need for further claims about the source of the idea for improved health services. I wish the Minister every good luck in the work he has before him.

In his closing remarks, Deputy Dowling was very reasonable on the question of the White Paper. If the line he suggests is adopted, I am sure the country will have a more satisfactory set-up in the matter of health services. I very much welcome that approach because it is in the interests of all that the health services should be put on a proper basis. Certainly, for the time being we cannot say we have such a service in this country. I doubt very much if we are likely to have it within a couple of years. The present financial difficulties will be an obstacle towards that progress. No matter how much the Minister or the House generally may desire an improvement in the health services, I am afraid we will have to wait for some time before we can get the machinery working.

I have no doubt the Minister is sincere in his efforts to improve the health services. He has taken pains to find out for himself what the conditions are. I must give him credit for that. In the course of the rather mild exchanges between himself and Deputy Esmonde, I got that impression from him. He was anxious to hear criticism. Where he thought the Deputy was in any way confused, he tried to be helpful. Furthermore, he has made it clear in the White Paper he will listen to all sections reasonably and accept whatever suggestions he considers practicable. If he does that and is reasonable in his approach, I have no doubt it will have the effect of bringing about an improvement in our health services.

I can claim to have some experience, having been a member of a local authority for about 23 years and having taken a keen interest in the workings of the hospital system in Mayo and elsewhere. We owe a debt of gratitude to the dispensary doctors, the nursing profession and the many charitable institutions and hospitals who have nursed our sick for generations past, long before health was made a subject of discussion in this House. These people have given valuable service down through the years. They did so without thought of remuneration or of the strain on their health imposed by long working hours. Today we are living in a much more materialistic age and many people when called upon to give service like to know what compensation they will get for it. The dispensary doctors who have given such valuable service down through the years should be treated generously, and I sincerely hope they will. We know there have been exceptions—and it is not easy to pinpoint these people —but generally speaking, they deserve well of the Minister and of the nation.

The same applies to the nursing profession. I believe they are a section of the community who have been badly treated down through the years in the matter of remuneration. I am convinced they are underpaid. As a result, many girls who would like to serve our own people in our own hospitals are forced to emigrate to England, America or even far-away Australia. I know that can be a good thing in itself because it is all Christian charity. But we have a problem here in many institutions of keeping our nursing staffs up to the required strength. It is becoming a serious problem. No matter how good the surgeons and doctors are, if we have not an efficient nursing service, the whole thing is a waste of time. In any consideration of the health services, special consideration should be given to the nursing service.

Mention has been made of the old people. That is a serious problem in the West. I visited a number of hospitals in my own county recently. I found there many old people lying in beds who, according to the medical and nursing staffs, could be out in their own homes, provided members of their families were prepared and in a position to look after them. But where are the members of their families? In many instances, I am informed, they are away in England or America because there is no employment for them locally. They went there when their parents were not too old and were able to look after themselves. With the passage of time, these young people have married and have had families and it is not possible for them to return for any great length of time. They just cannot afford it. No matter how fond they may be of their parents, they cannot leave their employment, and they have wives and families to look after.

That applies to the West more than any other part of the country. In the main the holdings of land there are small and, due to economic circumstances, these young people are forced to emigrate to supplement their incomes. In the long run, they probably stay away altogether and we find the situation in which these old people are occupying beds. In some cases the explanation may be that these old people, having no fire and no heating in their own homes, avail of the hospitals in order to keep warm and comfortable. I do not think they should be pushed out of these institutions and sent back to unsuitable homes in which there may be no fires or no means of providing them. I should not like that to happen but some means should be devised of looking after these aged people, thereby making hospital beds available for genuine patients in need of them.

Recently I had occasion to criticise the hospital services in Mayo. We have a long waiting list; the most recent figure was something like 55 waiting for admission to the county hospital. There is a long waiting list for X-ray. I cannot understand why there should be these delays. I have raised the matter at local level in the county council. These delays cause a great deal of anxiety not alone to the patient but to the relatives and friends because there is always the awful possibility that the condition of the patient may deteriorate considerably during the waiting period. Indeed, the consequences could be quite serious. Early diagnosis and early treatment might cure a patient; too late diagnosis, because of lack of X-ray facilities, may have dire consequences. Steps should be taken to correct this unsatisfactory position. The Minister should examine into the matter. I have suggested further X-ray facilities being made available in Ballina. Even if there were duplication of services, I do not think that would be any great harm. Minor surgical operations could be done in Ballina and patients could be dealt with in Ballina instead of being sent to Castlebar.

The Minister visited Mayo recently and saw things for himself. I certainly appreciated his visit on the sport, irrespective of whether it was made on behalf of Fianna Fáil or anyone else. At least he took the trouble to see things for himself. That is a good omen. It is one of the advantages of having a young go-ahead Minister who is really interested. I trust the matters I have raised will be considered in relation to any health legislation or the introduction of any health services he has in mind.

With regard to ambulance services, in Mayo the service could be regionalised to good advantage. There could be a link up with parts of Sligo, like Enniscrone and around that area. Patients from this area could be sent to Ballina and Mayo compensated for those patients by Sligo Health Authority. That would benefit the ratepayers and the service would benefit the people in the area. There would, too, be a better organisation of ambulance services. At the moment the position is very confused. There are occasions on which the ambulance is typing idle while a patient, perhaps a maternity patient, is taken by hackney car to Castlebar. Now I do not think it right that a young lad should be asked to transfer such a patient. There is no nurse with the patient and there is a certain risk involved. If anything did go wrong, the results could be very serious. The Minister should look into this whole question of ambulance services to see what can be done about them.

Speaking on the White Paper generally, I would ask the Minister to consider the position of the doctor who may have to travel ten or 15 miles to visit a patient perhaps in the middle of the night. A fee of £1 for such a visit is totally inadequate. That is the fee he would expect in a dispensary or something very close to it. He is called out at all hours of the night; he takes out his car and uses three or four gallons of petrol. There are many charitable people in the medical profession. The doctors who are in the locality in which I reside are charitable and would not be looking at the question of fees, but we should treat all these doctors fairly and reasonably. The Minister would want to have some proper means of remunerating these doctors.

The question of choice of doctor is very important. In that regard, there are the private practitioners, many or whom give excellent service. They get no remuneration from the State or from the county councils but they are in business because they are respected in their profession and because they give good service to their patients. Therefore, the private practitioners should be considered very seriously in the approach to the health services.

There are many grades of mentally ill people, starting with infants and going right up along the line to the very old people. This is a national problem. There is the problem of memtally retarded children. There are several categories of these, children who are a constant worry to their parents and relatives. We should be doing something about this problem instead of merely discussing it in 1966. Were it not for the help we have got from voluntary organisations, the Brothers of St. John of God and several other institutions, the position would be appalling. As it is, a great deal of the blame rests with ourselves because we have not made a practical approach to the problem.

It is not enough to call medical men together and appoint committees to inquire into the problem of mental illness. It is an exaggeration to say we have done nothing about it—that is not quite true—but I am not satisfied we have made the progress we should have made if we were interested in trying to find a solution to the problem. I would ask the Minister, as early as possible, to take the necessary steps to have institutional accommodation and suitable treatment provided for these people.

Mention has been made of the regional boards. It is a long time since I suggested the appointment of visiting committees in Mayo. I pointed out that the doctors were trying to carry on without any liaison with the local authority. The money was provided and it was spent in dealing with our sick people in the hospitals. The hospitals did their best but the co-operation that one might expect between the local representatives and the hospital authorities was not there. I appealed to the council at the time to appoint visiting committees to the various hospitals and, as a result of my efforts, these visiting committees were established. According to the law, we could not be paid travelling expenses in respect of visitations to hospitals. Some of them brought me a distance of 50 miles. I do not boast about that. I went there at my own expense, as did some of my colleagues. For a couple of years, these committees functioned very successfully within the county, because there was the added advantage that there were committee meetings with the people.

My colleagues and I who were engaged in that work were interested in helping in any way we could, and the medical staff and the nursing staff were glad to have our help and advice and to have an exchange of views. On many occasions we had to spend four or five hours trying to iron out problems of one kind or another. Then at a later date the new Health Bill was introduced with the provision for health councils. However, in Mayo and in other counties as well, these consultative health councils seemed to sink into oblivion. I do not want to be too critical but many of their activities were not known to the public at large. If the regional board is the solution to the problem, I would welcome it. Certainly there is a need for some new approach. There is the need for some type of board composed of people prepared to co-operate with the Minister and the local authority in bringing about an improvement.

Deputy Esmonde mentioned a figure of 2,000 patients as being the maximum a doctor can have. I do not know whether it is possible to stipulate whether the number should be 2,000 or 1,500. Naturally there would be a difference between the cities of Dublin or Cork and the rural areas. Two thousand patients in one place might be easy to deal with while one thousand in another area might be a problem. That is a matter the Minister would want to examine. I do not want to speak disparagingly of civil servants or to insult them—I know their intentions are good—but it is not always possible for anyone in an office in the Custom House or anywhere else to determine such figures, to put them into practice and make them workable throughout the country.

Health is a very important matter. A good deal of debate has already taken place on this Estimate. It is the duty of every Deputy to try to have a sound approach to the discussion. So far as I have heard that seemed to be the case. The Health Estimate was not made a political football. If it were, it would be a disservice to the people who sent us here to achieve the best possible health scheme for the country. If the Minister adopts the attitude that he indicated he would adopt today, of having consultations and listening to the arguments made, the result will be good. In my opinion he is a blunt man; he says what he has to say straight out even though you may not like it. I believe he is honest and sincere and that he will do the best he can. I can assure him he will have my full co-operation.

May I begin by congratulating the Minister on the White Paper? At no time in the past was the climate more favourable for the introduction of a proper health service. When the Minister first announced on Telefís Éireann the proposals of the White Paper, he made a tremendous impact, not because he was a member of the Fianna Fáil Party or of any Party, but because the people want a health service which will remove the inadequancies of the present service. They want something to which all contribute, something worthwhile and something that will bear comparison with the services provided elsewhere.

The time has come when politics will leave discussions on health services. For many years health services constituted a very important argument in politics but we have now matured and we look forward to a really good service as a result of the White Paper. I should like to pay tribute to the Minister's predecessor, Deputy MacEntee, because it was he who, many years ago, set up the Department of Health and strove to give a service to the people in his own time.

One of the greatest drawbacks of the present system is that people did not know what they were entitled to. There was mass ignorance of the benefits available and therefore people came to their local representatives to find out what they were entitled to get. He wrote many letters and made many phone calls on that account. I am against this sort of thing in public life. I do not see why anybody should have to come to me or to any public representative to ask if he can have a medical card. I think the White Paper may get it across to people that they are entitled to these services. Our people do not want anything for nothing. They realise you cannot get anything for nothing. That is why one is inclined to get mad when one hears the cry for a free-for-all. One knows there is no such thing, that it has to be paid for in some way.

That brings me to the point: who is to pay for the health services? I hope when the Minister drafts the Bill he will be very careful of the wage groups in which people have full free treatment because this is a very important part of the health service. We cannot, nor do we wish to give the so-called free-for-all service but we must ensure that nobody will be deprived of treatment because of inability to pay. That has always been the outlook of Governments here; they must ensure that people are not turned away from hospitals or dispensaries because they cannot pay.

The Minister called for a full discussion on the White Paper. People are discussing it to a great extent and I believe when the Minister drafts his Bill, bearing in mind the consultations he will have with various people, we shall get a Bill in keeping with our traditions and outlook. This is the age of preventive medicine. We have made some progress since the discovery of different drugs. Looking at the figures for tuberculosis, one sees a great drop. This applies also to infantile mortality and encourages one to think that these drugs will become more potent in curing all diseases. If we consider the deaths from cancer we see how much further we must go to provide a full service to stop this dread disease. I hope under Divine Providence scientists will soon discover a drug which will check cancer as previous drugs have checked TB.

There is a feeling in the city among medical and laymen that perhaps too many people go to hospital when it is really unnecessary. I want to relate this to the disappearance of the dispensary service which the Minister proposes to abolish, a step which I am sure will not cause anybody who knew this service to shed tears. I remember the corporation dispensary, as it was called, as a place painted a horrible dark green colour where the very atmosphere was repellent. I cast no reflection on the dispensary doctors, many of whom were dedicated men giving great service, especially in the poorer part of the city.

When we propose to abolish the dispensary system and provide a choice of doctor, we shall face a big problem. I propose that in place of the dispensaries we should have health centres staffed by five or six doctors. This would give a choice of doctor but the centre would be more than a mere dispensary where a patient would be told to take the red medicine today and the blue medicine tomorrow. Each centre would have a mobile unit that could go to the homes of the people. Years ago if one played football and broke a leg, one was brought to hospital and kept there for many weeks. Now, the leg is strapped up, put in plaster and one can go home. Similarly, a mother who has to go to hospital for a minor ailment worries about her children. She could have treatment at home and be attended by a mobile clinic such as the maternity hospitals use at present. This would benefit the patient and would also give a tremendous saving in the cost of hospitalisation.

Most of our hospitals in the city are over 100 years old which means very large maintenance charges and it should be our aim to reduce hospital charges as much as possible. The Minister, in paragraph 28, mentions this point and ends by saying: "The maximum use of out-patient services will be essential." In this city there are six federated hospitals. Under the new plan these will disappear and a new central hospital will be provided at Cherry Orchard. In different parts of the city we shall not have the hospitals we have at the present and that makes it all the more essential to have these health centres.

On the same point, I would ask the Minister to consider the establishment of an accident hospital in the city. At present we have many road accidents of all kinds, the victims of which are brought to various hospitals where beds may be available. If we had one hospital, the ambulance would know where to go. People might say that we would not have enough accidents to keep such a hospital going but the figures for Dublin alone for January showed that seven people were killed and 76 injured. That would keep a small hospital going for the Dublin cases alone. There is no fear that we will not always have a high bed occupancy rate as a result of accidents and also a high morgue occupancy rate.

I have referred to paragraph 28 of the White Paper and if we can reduce the numbers going into hospital, either by treating people at home, or treating them in the out-patient department, it would reduce greatly the cost of hospitals and would mean a new deal for the staff. I serve on a hospital board for the oldest hospital in the city and one of the most popular hospitals. It has a very dedicated staff and a very good Board of Governors who raise vast sums of money— apart from the State subvention—by voluntary means. In that way, they have been able to make many improvements to the hospital, but the building is old and every year we are spending money on a new roof, on new walls, and so on. Instead of maintaining these old hospitals for another 20 years, when federation will take place, would the Minister consider having a kind of temporary building, or a building which could be moved around? There would be very little maintenance charge for such a building and with proper apparatus, it would give a much better service.

The need for more hospital beds in the city is very apparent when we realise that a person who requires an eye operation in the one specialist hospital available may have to wait many months before being admitted because the hospital has such a long waiting list. The eyesight of a person who has an eye disease is being retarded all the time but the hospital can do nothing else as it is booked up for many months ahead. One of the greatest challenges is in regard to the provision of beds for retarded children. We know that there are many retarded children who could benefit from proper training but we have not got the room for them. We owe a great debt to the voluntary organisations in this regard but this problem is something which will have to be tackled strenuously between now and the implementation of the White Paper.

Another point which I should like to mention, and which may not be quite relevant, is that in the past the question of cigarette smoking was always introduced in these debates. There were people who were so fanatical about smoking that they drove people to smoking. You cannot order people around and people get fed up being preached at. While it has not been proved that cigarette smoking causes lung cancer, I believe that one is better off not smoking, but it is something which we must deal with intelligently in order to wean people from this habit.

In regard to mental treatment, Ireland is reputed to have a very high insanity rate. Some people challenge the figures and say that many people who have been sent to asylums recover but are left there because they have nobody to get them out. They are regarded as people who are mentally ill when in fact they are the same as the rest of us. This calls for some rehabilitation. The country cannot afford to have these people in the asylums. I look forward to the Minister giving this country the finest health scheme it ever had.

I have heard the British national health service being maligned in this House as not working properly and in essence as being rejected by the people. I am referring to this because what we in the Labour Party want is a health service somewhat on the lines of the British health service. Ten years after the British national health service was introduced, we had The Lancet, the medical journal in England, which is of the highest standing, referring to the health service as one of the biggest improvements in the life of the country since the war. We had The Times referring to the British health service when it said: “If judged by the health of the nation since its introduction, the service has been an unqualified success”. These words were echoed in millions of homes throughout England because the British national health service made a health service available to the people as a right of citizenship. It would be very unfair and very wrong if people were to say that the citizens of England rejected their national health service.

What have we here at the moment? We have a dispensary system and to dwell on this for much longer would perhaps be nauseating because we have come to the conclusion that this system must be abolished as being degrading to the people and as putting a stigma on the lower-income group who must avail of it. The Minister's decision to abolish the dispensary system is, perhaps, one of the best decisions I ever heard in this House. Apart from the dispensary system, we have too many out-of-date hospitals, too many make-shift hospitals. We have mental hospitals which are overcrowded and dilapidated and despite the gallant efforts of those who run the mental hospitals, they are incapable of and unsuitable for providing modern psychiatric care.

In the past 20 years, science in medicine has advanced as never before. We have the antibiotics, the vaccines and the recent advances in brain, heart and lung surgery, and the new techniques that have been applied in the treatment of mental disease. We have these magnificent advances and when deciding on a health service, what we want to do is match the achievements which science is offering us at present. It is absolutely necessary to match these achievements by the provision of a proper and adequate health service; but the ethical necessity for providing a proper health service is just one side of the picture.

We talk about providing a healthy and prosperous economy but this depends on a healthy and happy community. Ill health is an extra entry in the debit account and avoidable ill health cannot be justified at all. It would be as stupid to neglect our health services or to be satisfied with anything less than the best in that respect as it would be to neglect our industrial maintenance. The health of this country depends on the health of the people and because of this fact it is important that we provide the best in health services, not just improvement, nothing but the best if we want a healthy and happy community.

We would want to have the hospitals changed; we would want the waiting lists eliminated; we would want the provision of an adequate number of beds, fully staffed hospital beds. Large wards are a thing of the past and we must adjust our way of thinking about these wards and remember that patients are human beings who demand privacy. We should consider the provision of smaller units in hospitals, ward units of two or three beds and single rooms; we should see that these are provided for the ordinary people and that they not be just available for the privileged classes.

We want special casualty and accident units for all hospitals, units fully equipped for accidents in industry or on the road. This is what we need in our health services. We want special psychiatric units in all general hospitals to which ultimately all in-patients will be admitted. We want to see the abolition of all large mental hospitals. We want geriatric units attached to all general hospitals so that we can provide adequate, active treatment for the old in such a way that they will not become bedridden.

We want to see these hospitals provide better accommodation for the nursing and other staffs. Hospital buildings are important but much more important are the staffs that work in them. It is not too long since I was attached to hospitals in Dublin, and if I were to outline the conditions in which we worked and the conditions in which we lived in those hospitals, I would not be believed. It would not be believed that ten of us could live in a small room no bigger than a horsebox. It is a terrible indictment of the previous Minister for Health that he permitted the unhygienic and inhuman conditions in which we worked. We were treated like animals in a horsebox in these Dublin teaching hospitals. I would like to see better accommodation for the staffs working in the hospitals.

We must condemn the abnormal waiting time in our hospitals. We must condemn the fact that people should be compelled to wait all day long for attention. This prolonged waiting is due to the lack of specialised staff in these hospitals. We have a queue of registrars awaiting appointment to the specialised grade and no effort is made to have them appointed. The work hours which are lost by this cannot be calculated. We have a great shortage of specialised workers, physiotherapists, radiologists and pathology technicians. When we think of the modern advances in medicine in which pathology has played such an important part, we can understand why these pathology technicians are so necessary. In this regard there is a tremendous difference between this country and the United States where I worked for some years. There I saw a patient brought in at 5 o'clock in the evening and discharged at 12 o'clock the following day, after having had the fullest possible pathology tests carried out on him. The saving in expenditure alone in this respect is fantastic because they have adequate technical staffs in their laboratories.

We have a tremendous shortage of hospital catering staffs. Anyone who has spent any time in the public ward of a hospital will see how inadequate the catering staffs are. We would need to have the standards of the teaching hospitals more generalised. This could best be achieved by integrating the teaching hospitals under the regional hospital boards.

We must also think about the training of our doctors. Our doctors should be better trained in the specialised aspects of disease, in psychiatry and in industrial medicine. A good medical teaching is very essential to any health service and it must be individualised. Large classes and huge ward rounds may be gratifying to the teacher but will do little for the student. It is imperative that the Minister look into the question of medical education in our country. I can look back to the time when our medical degree was rejected in every State in America. I tried one state medical board after another and was told each time that the Irish medical degree was not accepted as being up to the required medical standard because the Americans came here and rejected our hospitals and our universities. It is very important that the Minister should look into medical education if we are to have proper health services in our country.

Mental health is a very important subject for consideration because we know that the mental health services have been starved of money. The hospital buildings are dilapidated and outmoded, we have a shortage of staff, the conditions for patients are often appalling, equipment is lacking and research in many mental hospitals is neglected. I do not think I will be contradicted if I say that more than half the hospital beds in this country are occupied by patients suffering from mental illness. More than likely it will cost a lot of money, but money spent on improving our mental health services would be very well spent. If we do this, we will find a large proportion of those suffering from mental illness will make rapid recovery and return to the community where their services can be used by society. In this way we can have many more useful citizens among us. Common humanity and practical economics combine to force us to attack this senseless waste of human material and I think it should be put on the Minister's list of priorities. I do not think it should be considered separately or put on the long finger. The Minister should not delay too long after he has seen the report of the Commission of Inquiry into Mental Illness. He should study it rapidly and act on it as quickly as possible as demanding immediate attention.

As I said earlier, we need psychiatric units attached to our general hospitals. This is very important. In considering it the Minister should realise the stigma of being an in-patient of a mental hospital. It is something only those who have been there can discuss. Knowing that our mental hospitals are under-staffed, it is important that we consider training more and more psychiatrists, more and more psychiatric social workers. Recruitment and training of mental nurses should be considered as an urgent problem and the proper accommodation of these staffs is very necessary.

We come to the question of the general practitioner in our health services. Good general practitioner care is the key to a successful health service and to good health in our community. The better the general practitioners do their work, the fewer patients we will have referred to hospitals and in this way there will be a tremendous saving of hospital expenditure. If our doctors operate a good general practitioner service, there will be no great demand on our hospital services but it is essential that the practitioner should not be overworked by too many patients—that he can carry out his work properly and be amply remunerated for it. Group practice is the only solution to our general practitioner service. The Minister might be well advised to look into the problem and recommend it, where possible, to the doctors because only then can doctors offer what is good and proper for the patients.

In considering the details of the White Paper, one thing I did not like in the Minister's statement is this excerpt from page 2:

Therefore, in opening my remarks, I think I should stress that the Government are not committed to all the details of what is in the White Paper.

I hope it is not the intention of the Minister to back down or perhaps put on the long finger some of the proposals in the White Paper. I was very disturbed by that statement. Perhaps the Minister would elaborate it when replying.

Mr. O'Malley

It just means it may well be that in reference to certain proposals outlined in the White Paper I may hear of better suggestions from Members of the House, members of local authorities and of the professions. It might well be that some of the proposals in the White Paper will not be feasible or sensible. Perhaps the phraseology was not entirely happy. What it means is that we are open to suggestions. There is a certain amount of elasticity.

I take it the choice of doctor is definite.

Mr. O'Malley

It is definite.

The choice of doctor is very important. Having worked with patients for so long and seen the other side of the picture many years ago when my family availed of the dispensary services, I can say there is something very personal, very intimate in the relationship between doctor and patient. A patient looks on his doctor as counsellor, friend, confidant and the best doctor in the world will not succeed in bringing about recovery unless the patient has faith in him. We can talk about brilliant doctors and their academic accomplishments but they are as nothing unless the doctor can bring about that rapport with the patient so very essential to the patient's recovery. The choice of doctor which the Minister proposes is perhaps one of the best innovations provided for. I know those who avail of the dispensary system at the moment will rejoice in the prospect of such a choice.

This brings me to the provision of a choice of chemist. It is very important that people should have such a choice. A choice of chemist will provide a boost for a patient's dignity. It will give him the feeling that he is not being subjected to abuse, that he is not accepting charity because he can pick his chemist. There is one disturbing aspect about the supply of drugs and in this respect there has been a suggestion about a national standard. I know we must have a sense of reality about the cost of drugs. If the Minister endeavours in these new proposals to limit the doctor in the choice of the drugs he thinks necessary for the patient, it will be disastrous.

Mr. O'Malley

I am not going to do that.

We so often see these unbranded drugs being purchased in dispensaries at present. I asked a question about it today. In this matter we are not dealing with television sets or mechanical gimmicks—we are dealing with lifesaving drugs. If we are to have imposed on us drugs of questionable potency and quality, death in patients could result. I had the experience of a patient dying with pneumonia due to the ineffectiveness of these questionable drugs. That patient was very close to me.

I am very much opposed to these drugs becoming freely available on the market. The pathologist in Sheffield proved that one particular drug supplied had no potency whatever. A child in Sheffield who received this antibiotic for pneumonia died. They could not understand it because the child had received the most effective antibiotic available. When the pathologist tested the drug, he found it contained plain raspberry syrup with no drug activity whatever in it. These drugs are imported from Italy, Bulgaria, Rumania and Poland. There is no research work carried out and no quality control exercised. These drugs cost a fraction of the cost of normal drugs. Anyone with an eye to the budget might say they are as good as the next.

But, as I said, we are not dealing here with television sets or anything where we might be satisfied with something of a lower standard of quality. We must ensure that life saving drugs serve the purpose of the patient. Does it matter if the right quality drugs are expensive when we feel we can rely wholeheartedly on the standards set by the companies manufacturing them? Price is immaterial where life is concerned. If the Minister in preparing a national formulary should consider including drugs of inferior quality, unbranded drugs over which no company can stand, we will oppose him whole-heartedly. He would be doing a grave disservice to the country and to the medical profession.

I dwelt at length on this because I think it is terribly important. Deputies not knowing this might find themselves in circumstances that they might require treatment themselves. Dublin Health Authority purchased £4,000 worth of these drugs recently and they are being made available to the people at the dispensaries. I showed the Minister conclusively that no quality control whatever was exercised over these drugs. There is a number on every bottle of the normal drug. If there is anything wrong with the quality of that sample, you can refer back to the original pack in the factory. This provides an instant check as to where the drug came from. But in respect of the drugs to which I refer the same quality number was on different packs. It was the most farcical thing I have ever seen. The secretary of Dublin Health Authority should be asked to explain why they purchased £4,000 worth of these drugs, despite the fact the Minister for Local Government refused to include them in the combined purchasing list.

On this question of district nursing and home service, it is important we have more district nurses who should work more in conjuction with the doctors. The home service is vital for the old. Many of these old people live alone and are in need of help. They suffer from loneliness and the fear of illness or accident. To have a proper home service available for these people would be a merciful act as well as being essential in a community health service. I hope it will not be available in theory only but will be properly instituted to be availed of by all these people.

It is good to see that the out-patient department charges will be abolished. In theory, the charges may seem small, but few people make one visit to a hospital. They have to go one morning for an initial check up; there is investigation on succeeding mornings, X-ray, pathology tests and so on. The accumulated charges are considerable and I welcome the Minister's proposal to abolish them. But would he not go one step further and abolish the hospital maintenance charges? There would be no abuse of the hospital in-patient service by abolishing these charges. Contrary to what the Parliamentary Secretary to the Taoiseach says, people cannot abuse that service. Doctors, and doctors alone, decide whether a patient goes into hospital or not.

It is common knowledge that people ill in hospital have the further anxiety about the hospital charges. Working class people when ill get only the national health social welfare benefits, which are small and inadequate, and from that they must provide the hospital charge of 10/- per day. The Minister says the full 10/- a day is not charged. I have yet to meet a case in which it was not charged. Despite representations being made, Dublin Health Authority refuses either to reduce or to waive the claim. District justices, on the other hand, are more humanitarian; they throw the cases out of court. The expense to which Dublin Health Authority goes in an effort to recover this money is quite uncalled for and neither Dublin Health Authority nor the health services benefit. Those of us who are members of the Voluntary Health Insurance Scheme may be a little complacent about things; we cannot imagine how 10/- per day could be a burden on anyone. But it can be a burden particularly on patients requiring nourishment. Very often relatives have to bring food to patients in hospitals and 10/- a day can be a great deal of money to these patients. I appeal to the Minister to abolish this hospital charge of 10/- per day. There will be no abuse of the hospital system and there will be rejoicing among the working-class people.

The Voluntary Health Insurance Scheme proposes to extend its services. I regard this body as a necessary evil. Two of its disqualification clauses are (1) that you are old and (2) that you are ill. If one has a duodenal ulcer and one avails of the benefits of voluntary health insurance, then one can be quite sure that will be a disqualification clause next year. They will never allow you to be treated again for this condition. Indeed, by a process of elimination, if you are the type of person subject to illness, you will ultimately be disqualified completely. When you are old and need hospital treatment, when you cannot shoulder the burden of hospital expenses, the Voluntary Health Insurance Scheme will not consider you.

I compare it to its disadvantage with a service in the United States in a town of 59,000 people. They have a local Blue Cross service and the benefits are far in advance of anything offered by the Voluntary Health Insurance Scheme. There is no question of the US Government paying any subvention into this. Yet, they can afford much better benefits than are afforded here by the Voluntary Health Insurance Scheme. I rather think that body is now trying to extend because they realise that, with an extension in other health services, there will be a smaller demand for voluntary health insurance. They are, therefore, proposing now to extend their services to domiciliary care.

The Minister says very little about school health services in the White Paper. These are very inadequate. It is stated in the White Paper that defects discovered at a school health examination will be attended to free under the health scheme. I asked the Minister a few months ago what would happen if defects were discovered outside of the school health examination and he said: "Just notify the school health officer and everything will be taken care of". Actually, under the provisions of the Health Act, the Minister was quite wrong in that statement. It is a pity he is not here now, but he certainly made a mistake. The service is available only if the defect or illness is discovered during a school health examination. These examinations are infrequent; they occur only every few years. Consider the position of a child with defective eyesight. That child cannot avail of these services unless the defect is discovered at a school health examination.

With regard to ophthalmological services, ours are the worst in western Europe. We have one hospital, inadequately provided with beds, to treat eye conditions. As one Deputy said, there is a long queue waiting to be treated for eye diseases and nothing is done about it. Let us hear something practical about this from the Minister. It is a very urgent problem. If treatment is not arranged immediately for glaucoma, the patient will go completely blind. Early treatment is vitally important. But how can this problem be tackled when there is a long waiting list? The system leaves much to be desired. The Minister should consider this as a matter of urgency. He should not even wait for the implementation of this proposed new scheme.

Our dental services are very bad. In this morning's paper the Irish Dental Association deplores the present system. After marriage young wives cannot continue with dental benefit scheme treatment. That is a real hardship, particularly on those who, before marriage, took an interest in dental health and dental care. It gives some idea of the inadequacies of our present dental health scheme. They say that the White Paper on the health services has failed to regard the dental service for school children as a priority service. Unless we start with the school children, there is no purpose in introducing any special dental health service later on. We are illogical in our approach to the problem unless we first provide a proper dental health service for children.

The people of this country can claim to have the worst teeth of any community, badly decayed, caries teeth. This is due in no small measure to our present inadequate dental health service. The Minister should examine the problem of the number of dental students and also the problem of the facilities in the dental schools for teaching students. Unless we start there, the problem will be as bad, if not worse, five, ten or 15 years hence. Very few dental students qualify each year, completely inadequate to cope with any service that would be envisaged by the Minister. What is the use of publishing a paper on what we want unless we provide an adequate number of dental surgeons?

There are other ancillary services in hospitals. Physiotherapy is a very important ancillary service which should be included in a health scheme. At the present time it is not, because I find that every patient I referred for physiotherapy treatment had to pay for it himself. There is no allowance whatsoever under the health scheme. Physiotherapy plays a very important part in rehabilitating patients after accidents and injuries.

The care of the aged is an important aspect of the health services and is so considered by the Minister. Hospitals are loath to take in old patients. It may be understandable because hospitals fear the patients might become permanently resident there if their relatives refuse to take them home. However, this fear does not justify hospitals denying old patients beds in hospitals which are urgently needed by old patients. From my own personal experience, I can speak of old patients who have died because there were no beds available in hospitals. I remember writing to the previous Minister for Health about one case. We waited and waited, and there was still no bed available and the patient died at home for want of hospital medical care. Time and again I was compelled to tell lies to the hospital authorities in order to have patients admitted. As soon as they hear the patient is 65 or over, they say: "We have no beds."

This is a deplorable state of affairs in a Christian country. We must face up to the fact that this does happen. The situation can be remedied if geriatric units are made available in the hospitals. Geriatrics has been given very little consideration in this country. We are inclined to accept the fact that old age is inevitable and that diseases consequent upon old age are inevitable, too. However, there are many problems of the aged that can be treated, and geriatrics is a very important side of medical science which should be given consideration.

The modernisation of hospital administration is also necessary. Those of us who have occupied beds in hospitals at some time know there is a lack of sense in the staff when a patient who is in hospital for a rest is wakened at 5 or 5.30 in the morning to suit the administration of the hospitals. This is a ridiculous state of affairs. It is so ridiculous that many a patient has been wakened out of his sleep to take a sleeping tablet, necessary because the administration says so.

Victorian methods and ideas are still employed in hospitals and patients must conform to the rules. The hospital services should be geared to suit the patient, not the patient to suit the hospitals, and the sooner we realise this the better. Another matter that should be considered is the food provided for patients. In his next speech, which will probably be made outside the House, the Minister should discuss with the hospital matrons the need to discard some of these Victorian methods and ideas, to adopt a more modern, humane approach to patients, realising that they are human beings.

Many Deputies have dealt with the subject of county homes. It is deplorable that many of our aged have had to seek refuge in these county homes, but it is still more deplorable that when an aged couple go into the county home, the husband goes one way and the wife goes the other way and they never see each other again. They are parted forever. A marriage union is broken up immediately at the door of these county homes. It is outrageous that the like of that should be permitted in a Christian country. Some means should be employed to correct this inhuman treatment of old people. The Minister would be well advised to tackle this as an urgent problem.

We in the Labour Party know what we want in a health service. We are not fickle about what we want; we are not vague; we are not ambiguous. Perhaps the Minister's plans and proposals are moving a little along the road to the Labour idea of a health service. We welcome that and we admire the Minister for his efforts. It is nice to think that an effort is being made in that direction and that the new Minister came to grips so quickly with this urgent problem. Many others perhaps would have turned the blind eye to it. In view of some of the things I have said, one might say that the problem is too big. I concede that the Minister is at least determined to do something about it. Let us hope that in the intervening year he will not be swayed from that determination.

It has been a long and hard struggle to get a Fianna Fáil Minister for Health to consider objectively the manner in which our health services should be reorganised. I have always felt it is desirable in relation to any consideration of our health services that we should not be inhibited by the present accepted divisions of the population into particular income groups or by the present system under which these groups are provided for. What I have advocated for a long time is that at some stage there should be an objective consideration by the Government or the Dáil of what kind of health services we should have without regard to what is there at present. It was to that end and with that object in mind that some 18 months ago, on behalf of my Party, I submitted to the Select Committee on Health Services a detailed memorandum setting out the case for the provision of a general medical service, a service based on our requirements in the present age.

In that memorandum, which has never seen the light of day, which has never been circulated to Deputies, there is contained a case for a new approach to reorganisation of our health services. It also contains a plan under which a comprehensive medical service can be provided for the entire population. We seem to forget—and I think this is one of the greatest weaknesses of the White Paper—that we are so far behind all countries in western Europe that even these proposals represent a form of health services which is out of date by some 25 or 30 years.

At present, apart from Finland, Ireland is the only country in western Europe which makes no provision for the general body of wage-earners and persons of limited means in regard to a general medical service. Apart from Finland, we are the only country that insists in our health policy that the average person must, in regard to the provision of medical care, fend for himself. When I say "we" I mean we who live in this part of Ireland because it is worth recalling, as we frequently forget, that our people who live in Northern Ireland have available to them a general medical service as they do in Britain, in France, in Belgium and all the countries on the continent of Europe.

What are we doing here? This Dáil is discussing a very limited and belated approach to the reorganisation of health services which is based on the policy contained in the Health Act, 1953, which has demonstrably failed. This White Paper now proposes a palliative, a bit of papering over of cracks in the 1953 Health Act policy. Where are we going? We are supposed some day to look forward to the reunion of our country: more immediately we are supposed to look forward to the day which, we are told will be no more distant than 1970, when we shall enter Europe. Do we seriously contemplate that the services set out in this White Paper will represent the high-water mark of the manner in which we are going to provide for our people within the European Community? If that is what we contemplate, there must be a great deal of fresh thinking on health services. If we go into Europe in 1968, 1969 or 1970, and even if the proposals in the White Paper are implemented, we shall not measure up; we shall be going in as a limping relative with a system of health services far below what any other country in the European Community regards as a minimum.

It is for that reason that I want to remind the House, as has been done already by Deputy Fitzpatrick and others, that while we are discussing here proposals which we welcome and which we do not want to be in any way ungrateful for, it would be very wrong for any Deputy to think that this little step forward can in any circumstances be regarded as facing up to the problem of health services here. I regret to say that in the entire White Paper there is still perfectly evident the old public charity approach to health policy. There is still the division of people into groups, into the haves and the have nots. There is still the idea that you must make regulations and provide safeguards lest people might get something more than what, on an exact and just means examination, they are entitled to. That kind of approach to the provision of health services is old hat, it is out of date, and I regret that a new Minister for Health, doing his best I have no doubt, should have been sold the idea that in modern Ireland that is the way to face up to health policy.

What are we doing here? We are abolishing the dispensary system and this is claimed to be a tremendous new step. We are hoping to provide a measure of assistance for the middle-income group in respect of drugs and medicines. We are hoping to provide an extension of the district nursing system for persons in the middle-income group and for the chronically sick and for old people. We are hoping to provide an extension of dental, aural and ophthalmic services to additional groups of people. These are the four provisions in the White Paper— abolishing the dispensary system, helping the average family in the middle-income group in respect of drugs and medicines, providing nursing services for the old and chronically sick in the home, and providing dental, aural and ophthalmic services.

I should like Deputies to take stock of what we are proposing to do. This is 1966 and in 1957 as Minister for Health, I announced a decision to alter the dispensary system, to modify it in order to provide for poor people a choice of doctor. That was nine years ago. I announced it just prior to the general election of 1957. I was not in a position to implement that decision because of a change of Government. Following the change of Government, I, on behalf of my Party, persisted in the idea and I tried to encourage the new Minister for Health, my successor, to accept that the choice of doctor, even while retaining a form of general medical service confined to poor people, was essential.

I made many speeches in this House; I spoke many times throughout the country to try to get that small penny to drop. I might as well have been out in the middle of a field baying like a lunatic for all the impression I made. It availed nothing. Through 1957, 1958 and 1959, right into the 1960s, anything that I said or Deputies in my Party or in the Labour Party said, fell on deaf ears. It was impossible to convince the Minister for Health that a small limited change of that kind to provide for poor people a choice of doctor could be made. In fact, may I remind Deputies that in pursuance of my idea at the time, and which is largely accepted now, I proposed that a number of the temporary district medical officer appointments in this city should not be filled and that instead a pilot scheme providing for a choice of doctor should be embarked upon in Dublin city? My successor, Deputy MacEntee, rejecting that idea proceeded to fill all these dispensary posts permanently. Indeed, as Deputies will recall, that led to considerable difficulty in certain parts of this city.

The decision to fill the posts was a decision to reject a very modest decision which I had announced as Minister for Health and the proposal which I had made that an effort should be made, even within the policy of confining a general medical service to poor people, to provide a choice of doctor. In relation to these matters, while towards the end of the 1950s the thinking in my Party was merely along the lines of providing a choice of doctor within the general medical service, we proceeded then in our thinking to go further and by 1960 and 1961 so far as the Fine Gael Party were concerned, we began to realise that providing a choice of doctor and abolishing the dispensary system were only temporising with the problem of reorganising the health services. We carried out some thinking in depth and we came to the conclusion some years ago that if we were to keep abreast of other countries, we had to contemplate, to the extent possible within our resources, the provision of comprehensive services, services which would be available to the bulk of the population, which would provide not merely a general practitioner service but also ancillary services, a hospital service, nursing service and so on.

It was as far back as 1961 that we detailed our policy of providing a comprehensive health service based on the principle of social insurance. I should like to recall to Deputies the fact that in the autumn of 1961 we incorporated our ideas in a Dáil motion. It was a motion in which we called for the introduction of a comprehensive health service based on social insurance. In the discussion on that motion, on behalf of my Party I gave to Dáil Éireann the details of our thinking in that regard. That was five years ago. Our motion was answered by the Government in an amendment tabled by them which sought to refuse the terms of our motion and proposed the setting up of a Select Committee. That is how the Select Committee on Health Services came into being. It was the Government's answer to our proposal, to set up a Committee to discuss the whole matter.

I do not want to make any criticism of the manner in which that Select Committee functioned. I hope that some day, and I believe the sooner the better, the Dáil will order the minutes of that Committee to be published. If they are published, Deputies and the country will see the frustrating experience that Deputies serving on that Committee who were interested in the reorganisation of our health services had to experience. I, and the other Deputies of the Fine Gael Party and the Labour Party, served long hours on that Select Committee, trying, day after day, to convince the representatives of the Government on that Committee that a change was possible, that it could be brought about, that its bringing about as a result of our common deliberations would achieve what we all desired, the removal of health and health policy from Party politics.

There was not one Deputy who seriously worked on that Committee who, at the end, was not convinced that its purpose was merely to prevent discussion of our health policy. It was in sheer desperation that in the dying days of that Committee, I was charged by my Party to prepare a memorandum setting out in detail what the Fine Gael Party stood for. I hope that some day this memorandum will be published so that the public and Deputies may see the depth and, I believe, the probity, of our thinking on this matter.

It is when one recalls these events that one experiences some surprise at the naïve statement contained in paragraph 53 of this White Paper where it is stated that the Government are aware of proposals recently made for the extension to the whole community of the general practitioner service, with free choice of doctor. I wonder how long it is necessary to keep on speaking before someone listens to what you are saying. The White Paper was published in 1966 and it refers to the Government being aware of proposals recently made. As far back as 1961, my Party moved Dáil Éireann to approve of the idea of a comprehensive medical service available to the entire community. In the years subsequent to that, we pursued that idea, endeavouring to convince the Government that it was necessary in the interests of the nation and possible with our resources. If paragraph 53 of the White Paper means anything, it means that the Government have only recently been made aware of all that we have been saying.

It is a pity that this closed mind approach to this important matter of health services should still persist. In the White Paper we are now getting the first small step forward. We are abolishing the present dispensary system to the extent that we provide a choice of doctor. That represents for Fianna Fáil now the Fine Gael thinking of nine years ago. Apparently Fianna Fáil have now reached the stage we reached almost a decade ago. How much longer will it be before a Fianna Fáil Government, if still there, will recognise the necessity for a general medical service available to the entire population?

I do not like to prophesy in this matter, but if our common hopes are achieved and if, next year or the year after, or the year after that, we find ourselves subscribing to the Treaty of Rome and entering the European Community, how quickly will it then be realised that a general comprehensive medical service is absolutely essential? If we do not do it within the European Community, we cannot possibly hope to survive. We have to have our health services and our general social legislation at least at the same level as already regarded as necessary amongst other European countries.

It is not a very large step. One of the difficulties I know the Minister for Health has had to contend with in even announcing these limited steps in this White Paper has been the complete rejection by his predecessor of all our proposals. He has made a limited step from that complete rejection by his predecessor but he has not been able to do much. One of the troubles has been the rejection by his predecessor and by the Taoiseach of our ideas for financing the health service. Fundamental to the idea of a comprehensive health service is social insurance. It is only when people realise that progress in social legislation and health services must be removed from payment by general taxation and local rates that proper progress can be made.

That idea is fundamental to our policy. It was rejected out of hand by the Taoiseach and the previous Minister for Health and it is because it was rejected that these limited proposals are contained in the White Paper. We all know well that if we are to try to finance health services by general taxation, we will be up against problems that no Government can adequately deal with. If we are to try to do it by a wedding of general and local taxation, we will be up against a difference in standards. That is one of the troubles we have had in the health services under the 1953 Act.

In some health authority areas, the indenting on local rates has been so hard that a lower standard is accepted because a health authority manager just cannot afford to increase the local rates bill. So since 1953 we have had different standards in different parts of the country because in some areas the ratepayers cannot afford to meet the added bill. In that respect, the Minister has announced that in so far as the cost of increases in health services are concerned, he will freeze the rates contribution. That is a slight step in the right direction, but it still leaves the problem which he is facing here and now that in so far as the cost of health services generally is concerned, it still has to be paid for by the general body of taxpayers, and so he can do nothing.

These White Paper proposals are merely put forward now so that they may be discussed, and all our discussions here will not achieve anything unless in the end money is found to implement them, and if money is found to implement them at the end of next year or the year after, whenever the green light is given, what will we achieve? We are to provide a choice of doctor for people who will be confined under regulations made by the Minister with the caution:

As a wide extension of the operating of State organised medical services has not been demonstrated to be necessary, the Government would regard it as undersiable. I would not therefore propose that the limits to be fixed by the regulations would be such as to include a high proporation of the population.

That is a clear warning that even when the abolition of the present dispensary system comes about, it will still be confined to the section of the population who at the moment are roughly covered by medical cards. There still will be the means test approach, the parsimonious approach. Why? Because to do otherwise would be to make the burden on the taxpayer undesirably high. When this bill is footed by general taxation, when can one expect another step forward? The plain truth will be that there will again be the old struggle between the Minister for Finance, anxious to keep down costs, and the demands of the Department of Health and other Departments to increase the quality of the services, and whatever progress is made in the general quality of the health services will be won after a struggle between the Minister for Health and the Minister for Finance.

That is axiomatic. It is bound to develop unless somebody, from today, begins to realise that the only logical way of providing against ill-health is by getting people intermittently, weekly, to pay while in good health for the cost of ill-health. It is one of the most fundamental concepts in relation to any way of beating health problems—the idea of a health insurance fund under which people in good health are asked to contribute the cost each week of ten cigarettes to cover the entire family.

It is only in that way that we can provide a general standard and that we can ensure that standards can be kept in touch with those obtaining in other countries. It is because there is not an acceptance of the principle of social insurance that this White Paper and the policy it contains is so limited, so confined. On this side of the House, we believe that in so far as our general health policy is concerned, the things we advocated in aiming at a just society are still valid. We believe that the ideals contained in that policy document are still sound, and while we must and do generously accept what is proposed here, it is very far short of what I believe is required.

It is indicative of the whole approach to this problem that in the White Paper no effort is proposed to provide hospital services. There should be free hospital services for ordinary people of limited means in this country and I fail to understand the mentality behind a policy which says that a workman who goes to hospital should be compelled, while sick and unable to earn, to meet hospital bills. That is an approach Victorian in concept that should have no place in modern thinking. We should have a system whereby every working man will be encouraged to stand on his own feet, encouraged to provide by insurance against the day when he becomes ill so that when he is ill and perhaps unable to earn, he will not have the added anxiety of hospital bills mounting up against him.

This absurd system is to continue under the White Paper. The only move in the right direction is to remove the absurd specialist charges introduced by Deputy MacEntee as Minister for Health in 1957. It was a wrong thing. The policy in this White Paper is merely building up on the Health Act policy and that policy, in my view, was wrong fundamentally. This is merely adding palliatives to try to deal with fringe cases, to try to paper over the cracks and make the health services something they cannot be. There is still the means test approach, the failure to stand back and examine the whole problem objectively. I do not want to go into any greater detail on these matters. My views and those of my Party are well known. I should like to add just one or two other things.

There is a proposal here that, while retaining a general medical service for people who establish the need on means test and in accordance with regulations, there would be some provision in aid given to persons who do not qualify under the regulations, and who are in the middle income group, in respect of drugs and medicines. Again, may I say that this is obviously an effort to meet the large volume of evidence adduced to the Health Services Committee which established beyond doubt—to my mind, at least— that the cost of drugs and medicines when sickness strikes in the home to the average family was crippling? I am going to prophesy that, if the Minister introduces a scheme whereby aid in respect of drugs and medicines will be given, if the expenditure exceeds a certain sum, he will find that just will not work. Once he introduces this, he might as well accept the necessity for some scheme of general application to help people in regard to drugs and medicines.

Our proposal in that regard, contained in the memorandum submitted to the Select Committee, involved the recognition that drugs and medicines should be available freely to all sections, outside those who are unemployed, sick or in receipt of social assistance, with the insurance fund paying half the cost. I believe the Minister for Health, whoever the will be, will sooner or later be forced to accept that necessity. Once you start providing that expenditure over a certain sum will be aided by health authorities, you are opening the door, and you might as well stand back and accept the necessity for new thinking with regard to this.

The White Paper also proposes the extension of the district nursing services. That again is something I welcome. We have advocated it for a long time and it is part of our policy.

The fourth provision here is the extension of dental, aural and ophthalmic services to additional groups of people. I was sorry to read that in the White Paper. It is not an objective or realistic approach. As Deputy O'Connell pointed out, it would be much fairer to admit that these services are not there at the moment for any group of people, not to mind additional groups. Do Deputies realise that under section 21 of the 1953 Health Act it was solemnly legislated that these services should be provided in accordance with regulations not only for the lower-income group but for the middle-income group, the bulk of the population? That was provided by a section in an Act of Parliament 13 years ago. These services never went into operation. They were never provided. Indeed, when I became Minister for Health, after I had entered into a solemn commitment to Deputies that I would implement the Health Act services—although I disagreed with the fundamental policy of it—I had a costing in relation to the provision of dental services and the other services in accordance with section 21. I found at that stage that under the manner in which the section laid it down, the cost was absolutely prohibitive. That was away back in 1954. Having learned that, I went to every local authority in this country. I concealed nothing. I told each health authority these services could not be provided and that the very best I could hope to do was to ensure that a beginning would be made in building up a proper school dental service; but beyond that, except in the case of absolute medical urgency in respect of bad teeth, nothing but a very limited public dental service could be provided.

My views as then stated have been repeated over the years. The dental, aural and ophthalmic services are no more than rudimentary. It is not because we have a shortage of dentists. We have plenty of them. There is no trouble in getting dentists, provided we pay them. Of course, it will not be possible to provide dental, aural or ophthalmic services of a specialist nature out of taxation. It just cannot be done and it is much more honest to admit it cannot be done. The only way any such service can be provided is under a scheme financed by weekly contributions. If that is accepted, then a great deal is possible. If that is not accepted, very little can be done.

We see here the extent of the thinking of a new Minister in regard to what is possible. Once a health policy continues to envisage the taxpayer paying by yearly injections the cost of health services, there is going to be a barrier all the time. Therefore, I feel considerable regret that there should be a promise of the extension of non-existing dental, aural and ophthalmic services. They are not there at the moment. It would have been far better if the White Paper merely contained an assurance that an effort would be made to provide these services for poor people. If we started by doing that, we might be doing something worthwhile.

I hope anything I have said will not be regarded as being in any way unduly critical of any person involved in the definition of health policy here. I do not intend it in that way, but I am very concerned about the continuance of a policy which I regard as unsound. Sooner or later we will have to stand back and have regard to the resources of the country and the best way of planning the service we should like to see here. We can do a great deal by community effort. We can do a great deal by having regard to the ordinary sentiments and habits of our people. I do not believe that anyone would object to paying a weekly sum in order to make provision for ill-health.

When I introduced the Voluntary Health Insurance Bill in 1956, I was told by some doubters that it would not succeed and that it would, in fact, require heavy subsidisation from the State. I believed in the idea of insurance. I believed in the fundamental good sense and decency of the ordinary people. I believed it would be possible, if the State gave the lead, to encourage people to provide against ill-health. I made a statement at the time which was regarded as being ill-advised; I said that the idea of voluntary health insurance would be the first social welfare scheme in western Europe that would not cost the taxpayer a penny. I am proud to recall that the hope I expressed then has been fully borne out. Innately the average father, or head of a family, likes to feel that by saving a little or by not spending a little each week or each month, he will be able to put aside, with other neighbours in a sort of community effort, something that will help somebody when ill-health strikes. That is the justification for social insurance. I believe it is the only way in which we will get a proper extension of health services and the kind of health services that will enable us to look forward to the reunion of this country without misgivings and to entering into Europe also without misgivings. If we do not to that, we shall always, have a problem.

In conclusion, the Minister and the Government have thought it necessary to have this White Paper debated here. I can understand the desirability of having a general discussion on health policy, but, after this debate, I sincerely hope it will not be found necessary to delay the implementation of these modified and limited proposals. Any step forward is worthwhile; any breakthrough is welcome. If we can get away from the monolithic approach to health policy, the approach we have experienced over the last decade almost, that will be a good thing. I should like to see these proposals implemented as quickly as possible after this debate. I look forward, as I have always looked forward, to the day when we will have an end to controversy on health. Health policy has bedevilled our circumstances here for far too long. There have been outrageous charges and countercharges. It is about time we realised we are a very small country with a problem which is limited in its nature; if we only have the faith and determination to solve it, we will make progress, and make it rapidly.

I congratulate the Minister on this White Paper. In it he has gone to the trouble of examining all our health services. I shall pick out one or two aspects in which I am particularly interested. It has been very wise of the Minister to decide on the appointment of more district nurses. Our Irish girls have a natural aptitude for nursing. That should be encouraged. Unfortunately, too many of them go to England. There they make excellent nurses and anyone who has ever been in hospital in England will tell you that Irish nurses are the best nurses.

The dispensary doctor, or whatever he will be called, should have at his disposal a district nurse. The doctor can do the diagnosis but it is the nurse who does the practical side of the work. She can give injections; she can do all sorts of things to help the patient. Indeed, with more district nurses available, it might not be necessary for so many patients to go into hospital. The difficulty now is that, because there are no nurses available, patients must go into hospital. With more nurses available for home nursing, more beds would be available in hospitals for urgent cases. Even with influenza nowadays, people feel they must go to hospital because there is no one with sufficient technical knowledge at home to look after them. Post-operative care could also be given in the home if there were nurses available for that purpose, thereby releasing beds earlier in the hospitals. There are no convalescent homes in the country. There may be some in Dublin. With nurses available for after-care, patients could go home much sooner. That would do away with the expense of nursing homes. The most important aspect, however, is the freeing of hospital beds, thereby doing away with the long delays people suffer at the moment while awaiting operations.

I am glad the Minister is to give people a choice of doctor. Making a choice is part of human nature. We like a choice, a choice of food, a choice of clothes, a choice of everything in this life. It is only natural we should like a choice of doctor. This move on the part of the Minister is very popular indeed.

I am glad, too, that the Minister is interested in mental hospitals. Killarney Mental Hospital is very over-crowded and patients cannot get the modern treatments to which they are entitled. The Minister has promised a new county hospital. The present hospital was the original workhouse and is quite unsuitable. In the proposed new hospital there will be a psychiatric unit. That will relieve the situation somewhat in the mental hospital. I trust the Minister will allow us to build the new county hospital as soon as possible so that we can have this unit and relieve the situation in the other. The mental hospital is overcrowded, with the result that there cannot be segregation of the mental patients. If a person who is not very seriously affected mentally—I believe the medical term is "disturbed"— goes into the mental hospital and has to mix with very severe mental cases, the chances are that that person will become as mental as the patients there already. If these patients could be treated separately from the severe mental cases that are in the hospital already, perhaps those disturbed people could be sent home in a few weeks perfectly cured, whereas by not being segregated, they may become so affected mentally that they will have to stay in the hospital for the rest of their lives. I would be interested to see the result of the mental health examination.

I am glad also to see the Minister is suggesting that there should be a determination of the people who are entitled to medical cards. The medical card is the only way of dealing with the situation but it creates many difficulties. There is no hard and fast rule as to who should have medical cards and what the income limit should be. The result is that people will say: "This person down the road has a medical card and she is very much better off than I am", and so on. If the Minister can say that a person of this income or that valuation is entitled to a medical card. it will make it much easier all round, and everybody will know whether or not he or she is entitled to a medical card.

As I said at the outset, this is a very comprehensive White Paper and I have just picked out those few points because I think they are the most interesting part of the White Paper. I congratulate the Minister and I hope he will be able to bring in soon as many of these proposals as possible.

I think I am in order in making reference to the vital statistics we received from the Department of Health this morning. They give the number of births for 1965 compared with 1964, In 1964, there were 64,072 births; in 1965, there were 62,600 births, a decrease of 1,472. At the bottom of the page, we find the statistics for deaths. In 1964, there were 32,630 deaths; in 1965 there were 32,778 deaths, showing that 148 people more died last year than the year before. If those statistics from the Department of Health are correct and we add them to the emigration rate from the west of Ireland, there will soon be nobody left there at all.

Page 5 of this document refers to major works in progress at 1st March, 1966 and mentions Carrick-on-Shannon County Home, County Leitrim. I do not know where the Minister got his information, but there is no work in progress on the extension of the County Home in Carrick-on-Shannon. I further want to tell him that the county manager told us at the last meeting that it was with the Department of Health or Finance for sanction and that it had not been sanctioned. We do not need ten guesses to know why it was not sanctioned— because there is not a "tosser" to pay for it. It is an appalling thing for any Department of Health to produce a document like that to try to mislead the country. There are a number of other places listed in it. I am sure the same thing can be said of them and, no doubt, other Deputies will make reference to them.

What page makes reference to Carrick-on-Shannon?

It is on page 5.

"At an advanced stage of planning" is the heading.

We could wallpaper the House with plans, blueprints and White Papers.

I must be losing my eyesight.

At the bottom of page 4, it says: "At an advanced stage of planning".

It is continued on page 5.

There is no sign of the work being done at all.

There could not be.

With reference to rural dispensaries, I am thinking of a place like Rooskey in my own constituency where there is a dispensary. I am thinking of another place, Newtowngore, where there is also a dispensary, where no appointment has been made and where a neighbouring doctor is doing the work. I believe that when this scheme comes into operation, no doctor will reside in any of these places. We shall find ultimately that he will be moving into a bigger town and operating his dispensary from there. He will move into towns like Longford. Carrick-on-Shannon and other big towns.

Paragraph 45 on page 22 of the White Paper refers to the erection of houses for medical practitioners. I am a member of Leitrim County Council and we had the experience of building a dispensary residence for a doctor in a place like Newtowngore. It was built for ten or 15 years and nobody ever went into it. The local dispensary doctor would not go into it and he could not be compelled to occupy it. The net result was that the local authority had to demolish the house. There is the danger of that situation arising again and I feel it my duty to mention it to the Minister.

Reference has been made to district nurses. We had a few district nurses in a County Leitrim and they resigned, probably to move to other jobs, and we have been trying since to force the county manager's hand to make an appointment, and he refuses to do so. I should like the Minister to use his good offices to see that these appointments are made. For some unknown reason, the county manager will not do it.

I feel obliged to refer to medical cards. Looking at the number of medical cards issued in each county. we find that Carlow tops the list with a percentage of 47.1, while Leitrim, the poorest county in the country, is third from the bottom. Dublin County and, I think, Dublin County Borough, are below it. Leitrim has a percentage of 24.4 per cent, and Sligo 28.2. These two counties are operated by the same county manager and it clearly indicates that the manager makes the decision. I do not know what standard of judgment he uses. When we look at counties in some away comparable with Leitrim, we find Roscommon with a percentage of 44.9 but there is a different county manager. Longford has a percentage of 45.9—again with a different manager. I think the Minister will admit that it is a desperate situation when a county manager can make decisions like this, giving Leitrim the smallest percentage of medical cards in the country.

We were all very hopeful that the medical cards would be done away with under the new health scheme but, unfortunately, this is not so. One cannot help recalling the days of the red ticket that many people were glad to get rid of. These tickets were usually issued by a local councillor, very often by a local publican or teacher, and in many cases, my honest opinion is that these people had a better idea of who should get tickets than the present county manager. One does not like to go back—we should make progressbut I think the people of Leitrim would be much more comfortable and better off if the medical card had never come into existence.

I also felt that under this health scheme cancer cases should be treated free. According to the statistics, the number of people who died from cancer in 1964 was 4,953 and in 1965, 4,962, an increase of nine. When the Minister is considering this, I hope he will think about getting the local authorities to accept full responsibility for unfortunate people struck by cancer.

Some changes have been made in income groups. The old valuation was £50 which is now increased to £60, while the income limit has moved from £800 to £1,200. The net result is that under the old middle-income group, 85 per cent of the total population qualified for free medical service; with the present increases, it will mean that 92 per cent of our people will qualify, leaving only eight per cent who do not qualify. That is a good achievement, but, like other speakers, I should like to plead on the question of the 10/-per day charge for hospital treatment for people in the middle-income group.

The Minister tells us that in some given year, 60 per cent of that group paid nothing, that 20 per cent of them paid 5/- per day and that the remaining 20 per cent paid only 10/- per day. One might think that when we take into account the time lost in county council offices in handling hospital accounts and the time spent by local home assistance officers on investigations and so on, with the people ultimately going to a public representative to get their bills reduced or wiped out, in the final analysis, it is doubtful if the Department of Health saves anything by it. The figure of £500,000 was mentioned as the income but if the cost of sending out bills and investigating were deducted, it would not amount to much. I should like the Minister to reconsider this.

People in the lower and middle-income groups should have free choice of hospital without going through the present channels. If one of these unfortunates becomes ill he is probably moved to a hospital in his own county. The surgeon has to say that he is not in a position, has not the facilities, or is not capable of dealing with that particular case before he can send it to an external hospital. If the Minister, under the new system, gave power to the local dispensary doctor to decide where the patient should go, it would be a big improvement.

The question of mentally ill and mentally handicapped children is being dealt with by a Commission set up in 1961. This is 1966, and one would think they should have completed their report by now and that this House would be able to do something about it. I ask the Minister to try to expedite the report of the Commission as much as possible. In counties Leitrim and Roscommon particularly, there are a number of mentally handicapped children who cannot gain admission to institutions. Such places seem to be full and there seems to be no hope of getting them admitted. Quite recently a patient was returned to the parents from one of these institutions after being away one and a half years. Now the county MOH and everybody else are trying their best to get this mentally handicapped child placed.

Finally, before this scheme can be implemented or before anything is done about it, there must be agreement with the doctors and we must also find sufficient money to carry out the proposals. If I remember correctly, the Minister on television said the total estimated extra cost would be in the region of £4.5 million per annum for health. He said that he hoped to have it in operation by 1967. I hope he is right. He will have my blessing and the blessing of this Party if he gets it into operation as quickly as he can. Every Deputy knows that there is a great necessity for a change in the health scheme, but one is inclined to ask one-self if this is a smokescreen because no later than a few weeks ago the Taoiseach said that there was no money for health or education. It is funny that these are the two things which have come up for discussion here, education last week, and health this week. I hope that money is available and that the Minister will put this new health service into operation at a very early date.

Mr. O'Malley

I should go on record as saying that the Taoiseach never made such a statement——

He was quoted in the public press.

Mr. O'Malley

——as attributed to him by the Deputy.

(Interruptions.)

The birds on the bushes know it anyway.

I should like to welcome the proposals in the White Paper. Each of them will be an improvement on the 1953 Health Act. I do not wish to criticise the 1953 Act as I believe it was a very good one. The only defect that could be found in it was in the way it was administered by the various. county managers. Perhaps we expected too much of the county managers because the Act was rather difficult to administer, for the simple reason that it did not clearly define who was entitled to a medical card and who was not. You had the position that a single man in one county with a wage of, say, £7 10s., qualified for a medical card, while perhaps in an adjoining county, a married man with a child, and with the same wage, failed to qualify. I need not stress the confusion which was caused by this position. I know from experience that some of the county managers did an excellent job. The two county managers with whom I deal, namely, those in Waterford and South Tipperary, both did an excellent job and were very liberal in their administration of the Act. As far as they were concerned, anyone on whom it was a hardship to meet his medical and hospital expenses was not called upon to do so. From what has been said, it appears that it was not so in other counties.

We also had the position that when a person applied for a medical card, the home assistance officer, who was the investigating officer, was more inclined to be guided by what perhaps would suit the county manager as to the percentage of medical cards in the county, and he was inclined to keep down the number, perhaps with a view to keeping the cost on the rates from increasing enormously. On occasions he considered the case on whether the person gave the impression that he was well off, whether he was the owner of a motor car or a television set. If the person was the owner of either of these, he was not considered eligible for a card. He considered that anyone who could own a motor car or a television set was well able to pay his medical expenses and, he paid no regard to the fact that a motor car might be necessary for the purpose of carrying the breadwinner to work, perhaps on a long jounrney, or to bring the family to town or to Mass, or to the fact that the television set might be providing entertainment for some old person who was, perhaps, confined to the house.

I am mentioning this because, to my knowledge, that was the way in which a number of the investigations were carried out. This was entirely wrong. I welcome the proposal in the White Paper to define more clearly who is entitled to a medical card. Those who were refused medical card. Those inclined to worry unduly that if they became ill, they would have to pay for their hospital treatment, their medicines and drugs. Some two years ago, when visiting a hospital, I was asked by a neighbour who had been unfortunate enough to have an accident, how he was to meet his hospital bill. From his injuries it appeared that he would be in hospital for at least 12 months, and he was worried that he would not be able to pay the 10/-a day which he would be asked to pay. I pointed out that he would not be asked to pay anything because he was now unemployed, but he was not inclined to accept this. He said: "You know, I applied for a medical card some time ago and was refused, and in the circular which I got back, I was told that I belonged to the middle-income group and because I belonged to that group I will have to pay 10/- a day for my hospital services." This is typical of what the public had in their minds. They felt that if they were refused a card and had to go to hospital, they would be charged 10/- a day. They forgot that because they were now out of work and their circumstances had changed, they were entitled to a medical card.

I am delighted that what is commonly called the hardship clause is retained and that anyone with undue family illness, regardless of income, can be considered for medical treatment. I know that there will be big difficulty in regard to fitting farmers into the different classes of medical groups. A valuation is a very poor guide to a farmer's income. A farmer in one district with a £20 valuation could be reasonably well off, while in another district a farmer with a £50 or £60 valuation could be in very poor financial circumstances. This is a very difficult problem and something which will require some working out.

I welcome the proposal to have a choice of doctor for the lower-income group. In the past we had too much distinction made between those who had medical services provided for them and those who were paying for their own treatment. Some dispensary doctors were inclined to make a class distinction and this caused considerable embarrassment to those who are not in a position to pay for themselves. This is entirely wrong. I do know that all dispensary doctors were not giving the service they should, but at the same time, I would like to take the opportunity of paying a tribute to them for the wonderful service they gave in the past and are continuing to give. Most people must admit that the majority of them are dedicated men. Unfortunately, a small number got a bad name for the rest by not giving the service they should give. That small percentage tried to make those people who could not pay feel that they were getting something for nothing.

It is gratifying to see from the White Paper that medicines and drugs will now be made available to the people at a chemist of their choice rather than that they should have to go to a dispensary and queue for hours in some old draughty building, then perhaps be told that the chemist there had not that drug available and to come back tomorrow. There was no regard for the fact that these people might have travelled a long way at great inconvenience. There was no regard for the fact that they may have had to hire a car or come by bus and that they could ill afford to spend money in that way. I welcome the fact that supplies of drugs and medicines will now be made available at a chemist of choice. This is the just right of the people.

Provision was made in the 1953 Health Act to have drugs and medicines made available to those outside the lower-income group if it was a hardship on them to meet the cost themselves. That provision was not availed of until recently when people became aware that such a facility was available following a circular from the Minister asking the health authorities to give medicines to those who applied for such services. This will help to alleviate the worry caused to people when they fell ill and when expensive drugs were prescribed for them. This is only as it should be.

It is envisaged in the While Paper that 92 per cent of the people will quality for the health services. The middle income group has been widened to bring in those with up to £1,200 a year and farmers up of to £60 valuation. Speakers from the Opposition benches have suggested that we should go all the way and abolish the 10/- per day hospital charge. This suggestion is worth considering and I would point out to the Minister that in the main hospital of Waterford Health Authority, with an expenditure of £226,000, only £60,000 was collected under section 15 and there were a lot of administration costs involved in that. I would ask the Minister to give that aspect of the situation serious consideration.

Our investigation officers are called home assistance officers and I believe the title should be changed to that of social welfare officer. That change would be desirable. I would congratulate the Minister on the interest he has taken in the care of the aged. In the town of Clonmel we have a committee which organises parties and outings for old people. I suggest that there should be greater liaison between such committees and the local health authorities. It costs between £14 and £17 per week to maintain an old person in a county home and it would be a great help if some of that money were made available to these local committees who are helping out. It would help to keep these old people in their own homes which is a very desirable thing.

Loneliness is one of the things that affect old people most. Local committees can do an awful lot to get over this by visiting them and by having parties and outings and if some money could be made available to these committees it would be a great help. When a person finds it necessary to go to a county home, some small home should be provided in the centre of population nearest to them. In Clonmel and district people who find it necessary to enter a county home have to go to Cashel, 15 miles away and if they live in the Waterford end of the county they have to go to Dungarvan, which is 30 miles away. For a time they are visited by their relatives but as time goes on these visits are not so frequent and the old people feel neglected. That is why we find it so difficult to get our old people to go into county homes. Every effort should be made to provide accommodation for them in the centres nearest to their own homes.

These county homes do excellent work and look after those people in an excellent way but these old people find it difficult to fit in with the routine, the discipline and the regulations. They have had a certain amount of freedom all their lives and they find the restrictions rather trying. I would again request that if money could be provided to help the local committees I have already mentioned in their efforts it would be money well spent.

I welcome the suggestion that health authorities be organised on a regional basis. This is the proper thing to do and it is very desirable from the point of view of the patients. It would give them a wider choice of doctor within their region and greater flexibility in the choice of hospital. Patients would have the choice of the service nearest to them and these areas should not be left at the county bounds. A larger functional area for the health authority would reduce the financial burden considerably. It would give better regional ambulance services which would be much more beneficial and far less costly to run.

Take my county, Waterford, as an example. The main hospital is situated in Waterford city. I live on the borough boundary of Clonmel and I see ambulances operating daily into my locality from a distance of 35 miles away while we have the South Tipperary hospitals at our doorstep. People should have the right to avail of the hospital services nearest to them. In the same way, there are ambulances operating to the Cork border, a distance of 60 miles. The natural bent of our people is to avail of other hospital facilities within 35 miles of them. When regions are set up, we can look forward to improvements in the ambulance services. In this context I suppose it is right to say we have arrived at a time when ambulances should be equipped with radio communication. In conclusion, I congratulate the Minister on the White Paper. We can look forward to many improvements in the years to come and we wish him every success.

Before Deputy Reynolds of Fine Gael concluded, the Minister for Health, for the record, contradicted him in relation to a remark made by the Taoiseach some days ago. The Taoiseach was quoted in the Press as having said something and now the Minister for Health denies that the Taoiseach said there was no money for health or education. I should like to put it on record that on page 9 of the White Paper, the Minister makes this statement:

The changes proposed are complex and fairly costly. Their complexity rules out any question of their introduction in the immediate future, as it will take some time to prepare and consider the legislation which will be needed to give effect to them. Expenditure on developments in the services of the order proposed could not, in any event, be undertaken in the existing financial circumstances.

I should like to ask the Minister is he right or is the Taoiseach right?

Mr. O'Malley

Will the Deputy tell us what the Taoiseach said? He does not quote him. I shall wait until the Deputy goes to the Library and gets the quotation.

(Cavan): Irrespective of what the Taoiseach said, there is no money.

For the record, the Minister for Health contradicted what Deputy Reynolds quoted the Taoiseach as having said. The Minister has given the House to understand that there is no scarcity of money.

Mr. O'Malley

Who has?

Perhaps the Minister agrees there is a scarcity of money?

Mr. O'Malley

Of course there is.

A few moments ago the Minister tried to imply there is no scarcity of money. Now that at last we have agreed, I shall proceed. I read the White Paper with mixed feelings. I have always admired the Minister for Health who, as Parliamentary Secretary to the Minister for Finance, was dynamic, sensible and down to earth. I felt that when he was appointed Minister for Health he would tackle the new job thoroughly. I could imagine the Minister taking up the cudgels of office in that Department, seeing all the things that had to be done, listening to all the accounts put forward by Fine Gael in their efforts to move towards a just society. The just society aim was put by Fine Gael to the electorate.

Mr. O'Malley

And what happened?

It was fundamentally based on Deputy T.F. O'Higgins's Health Act which the Minister now tries to copy but which his predecessor decried and in relation to which, during different by-elections, backbench Members of Fianna Fáil put down questions to their Ministers.

Unfortunately the Fine Gale policy did not include pep pills.

This was an endeavour to frustrate the electorate, an ordinary tactic of Fianna Fáil—they ask a question, knowing the answers. In many cases the Minister has seen the things that were wrong in the 1953 Act and I congratulate him on trying to change them. However, it must be very frustrating for him to sit in a ministerial chair behind a ministerial desk and find that the Government have squandered all the money with which they could have implemented——

Mr. O'Malley

We spent £31 million last year.

I do not know how much you spent on Potez in Galway. It would have been better spent on health.

Mr. O'Malley

Let us be constructive.

The Minister realised that the community were not getting value out of the 1953 Act. The last Fianna Fáil Deputy who spoke—I do not know his name——

Mr. O'Malley

Deputy Fahey.

——endeavoured to make a case for the 1953 Health Act. Members of the House who are members of local authorities know the dilemma facing county managers, superintendent assistance officers, assistance officers, members of local authorities, when they discover that in many cases holders of medical cards own motor cars and that in many cases holders of medical cards are very rich people. Let us not blame the people who try to administer the Health Act. Let us rather blame the people who designed the policy and who created a situation in which such things can happen. We all know the medical card system is bad, that the 1953 Health Act is bad. I may be criticised and a dim view may be taken of me when I say that the man responsible for that Act was also responsible for having the calves slaughtered in the 1930s and for imposing the abominable turnover tax.

It does not arise.

Perhaps it is not fair of me to say that if that man were responsible for such policies as the slaughtering of the calves and the imposition of the turnover tax, he was equally unable to forecast the results that would follow the introduction of the Health Bill in 1953.

I am a member of Donegal County Council which is the health authority for County Donegal. As the representative of a rural constituency in western Ireland. I feel that the 1953 Health Act was wrong in that 50 per cent of the cost had to be borne by the ratepayers with a 50 per cent grant from the Department. In such a situation, a county such as Donegal could not provide a health service akin to that provided in Louth. Louth has a population greater than Donegal but its area is only about one-fourth that of Donegal. In Louth, there is richer land, more industries and taxation is spread more evenly. Therefore, Louth Health Authority can provide a better health service for their people than Donegal Health Authority can provide for theirs. That is wrong. I feel it is an infringement of the Constitution. It means that in Louth people earning £10 or £12 a week can hold a medical card, while people earning half that amount in Donegal may not hold a medical card. I would say to the previous speaker that you cannot blame the county manager for that. If he is to give a service equivalent to that in a richer county, the rates must go up. The rates in Donegal are 20/- in the £ greater than those in Louth. I welcome this new thinking on a regional basis, but I still say the Minister should accept completely the Fine Gael policy on health.

Mr. O'Malley

What is that?

You have read enough of it to pick out the good points. You should read the rest.

Mr. O'Malley

Did I leave something out of the White Paper?

I do not wish to be impertinent but I think Deputy O'Higgins reminded the Minister that he wrote most of it. I think we should leave it at that. Many members of Fianna Fáil who are members of local authorities are frustrated so far as medical cards are concerned. We hear them proposing amendments to the 1953 Act at various council meetings, asking the county manager to do this and that. After a discussion lasting two or three hours, they are told the county manager has no authority. I am informed that at a recent meeting of the Association of Municipal Authorities a proposal was made to define income and say exactly who is entitled to a medical card. When this was put to a vote, Fianna Fáil voted en bloc against it. I hope some Fianna Fáil speaker will confirm or deny that before the debate concludes.

One of my big complaints in regard to the 1953 Act concerns the school medical service. We were told that all children of schoolgoing age would be entitled to free medical treatment and hospitalisation without means test. The sky was the limit, and rightly so. The Minister is a sensible man. He knows that that might apply in theory but that it has never been achieved in practice. I know of cases where parents discover a child is handicapped either physically or mentally. They are anxious to do what is best for the child. Let us say they are in the middle income group. They take the child to the local dispensary doctor or a private doctor. He recommends the child be sent to a specialist and the specialist recommends hospitalisation or some form of treatment. Let us say the child is aged anywhere from six months to four years of age, anywhere under schoolgoing age. If the parents disclose to the local authority there is something wrong with the child before it undergoes the school medical inspection, the means test is introduced and they must pay. I know of one case where parents coming from the middle-income group had a mentally handicapped child. They had to pay £3 10s per week for the maintenance of that child in an institution. They appealed against that and it was reduced to £2 per week. I know of another case—not in Donegal but in another county—where a bank manager whose wife is a school teacher also have a mentally handicapped child. Because they brought that child to the school medical inspection, they have free medical services for it.

Our society should not tolerate such a situation. I am all for free medical services for mentally handicapped children, for the poor and the disabled. I feel the only way society can provide good social conditions is by providing free medical services for all. If the higher-income group and middle-income group are prepared to pay to provide the services for the middle-income group and the lower-income group, I see no reason why, if the three groups work together and pay a little extra, we cannot provide health coverage, as the Fine Gael policy proposes, for 85 per cent of the population. I know the Minister would be very anxious to implement fully "Towards a Just Society". I know that the very idea of it shook the Fianna Fáil Party to their very foundations during the 1965 general election. The Minister may smile but at the beginning of the campaign we were a crowd of hypocrites; as the campaign moved along, suddenly the hypocrites were not all in the Fine Gael Party.

Hear, hear.

Some of them found their way into the Fianna Fáil Party and we had the former Minister for Health, Deputy MacEntee, admitting that the structure of the health services would have to be changed. Why had it to be changed? Was it because overnight he discovered it was wrong or was it because the Fine Gael Party had published their policy and the people were beginning to accept that policy and Fianna Fáil suddenly recognised a change was necessary? All that leads me to believe that the present Minister is very much in love with the Fine Gael policy "Towards a Just Society". I am sorry for the Minister in his present dilemma; he has not got the money to implement such a policy.

Deputy O'Higgins explained in considerable detail earlier this evening how the just society would be financed. If the Minister did not listen to Deputy O'Higgins, I urge him now to read his speech before he comes to conclude this debate. Is the Minister actually reading the speech? That is keen anticipation. I hope he will pay particular attention to it when he is replying.

Mr. O'Malley

The Deputy can say that again.

(Interruptions.)

With regard to school medical inspections, my complaint is that if parents take a child to a doctor or specialist before the child is registered at school they commit themselves to paying so much per week whereas, if they wait until the child goes to school, and have the child examined during the school medical inspection, treatment is free. The Minister does not propose to change that.

Mr. O'Malley

I shall deal with that in my reply.

The Minister has not made up his mind.

Mr. O'Malley

I have.

Perhaps, when he has read Deputy O'Higgins's speech, he will agree on that as well. Very often at school medical inspections recommendations are made that teeth be extracted, tonsils removed, or some other ailment attended to. The usual pattern is that, by the time the child is sent for four years later to have treatment, he is working in Manchester, Birmingham, London or Glasgow. I wonder how much time it takes to have these school medical inspections. I wonder is it right to have them and not carry out the recommendations.

On page 44 of the White Paper, the Minister refers to the care of the mentally handicapped. It is stated that a commission of inquiry was set up and the Government do not propose to discuss this particular matter until they have considered the report of the Commission. That is a slick way of evading an important issue and shelving a very serious problem. Of all the complaints that beset our modern society there is none so neglected as the care of the mentally handicapped. If it were not for the voluntary societies, I do not know what kind of situation we would find ourselves in. Perhaps in two, three, four or five years' time, the Government will be in a position to tell us what they propose to do for the mentally handicapped. I state most emphatically now that the parents of these children and the voluntary societies interested in this problem are not interested in what the Government may do two, three, four or five years hence. What they want to know is what the Government propose to do now.

Only a few days ago I had occasion to go into a hospital in this city and there I was informed that the child in whom I was interested would be admitted in September, 1968. Incidentally this hospital is run by a voluntary association, an association attempting to solve the problem the Government are treating with—this may be too harsh a term—something very close to contempt. I feel very strongly about the lack of care of the mentally handicapped. If some of the glamorous Government ideas which Deputy Reynolds mentioned earlier, glamorous ideas used as smokescreens, were forgotten and some of our Ministers got their feet on the good solid earth and moved out into the homes in which there are mentally handicapped children, they might rid themselves of some of the complacency that now enshrouds them. The voluntary associations do not, in my opinion, get enough credit for what they have done and are trying to do to solve this particular problem. Only that voluntary associations have spotlighted this matter and created public opinion to force the Department of Health and the Government to do something about it, even a Commission would not have been formed to examine the problem.

This is a problem which, as a public representative and also as a politician I have at all times tried to keep out of the political arena. However, it has reached such a serious stage that I feel that it is time to face up to the truth, and paying compliments to the Minister or to officials in the Department of Health will solve nothing. I could go deeper into the subject but I would prefer not to and to ask the Minister to give every assistance possible to voluntary associations who are trying to solve this problem.

There is another point I should like to make and no doubt you, a Leas-Cheann Comhairle, are also aware of the situation as it exists in Donegal, and as a member of the health authority you have heard various members of the council expose the bad conditions in dispensaries.

The Deputy should leave the Leas-Cheann Comhairle out of the discussion.

I do not propose to bring the Leas-Cheann Comhairle into the argument but it is only right and proper that, as a Deputy I should call on you to vouch for the truth of what I say. I have visited some of these dispensaries with a person who is a very responsible Senator of the Fianna Fáil Party and who has on numerous occasions brought forward motions at county council level to force the hand of the Minister in advancing money to provide dispensaries so that people can be treated as human beings when they visit the local dispensary doctor. During those times, I have become acquainted with the conditions of these dispensaries and I have spoken to the doctors.

One of the stupid—and there is no other word to describe it—situations which exist at local authority level is something like this: a doctor can requisition for a medical card holder any medicine at any cost from the dispensary, and it can sit on the shelves of the dispensary until it rots. Money can be poured down the drain in respect of medicines, and has gone down the drain. However, if he asks for £5 to put a pane of glass in a window, an engineer must come out and inspect it. He must report back to the engineering section and a workman will be sent out to fix it. When it is fixed the workman will report that the job is done and the engineer comes back to examine that is it properly done. There is all this red tape for a cost of £5. A more commonsense approach should be used. If a dispensary doctor wants better facilities in his local dispensary for the comfort of his patients he should have the same entitlement to provide those comforts as he has to requisition drugs or other medicines.

One other matter which is not properly examined in the White Paper and which, to a degree, has been neglected by the Department of Health is the care of the aged. The Deputy from Waterford who has spoken asked why the Department of Health and the local authorities did not try to provide local homes for their people and prevent them going into what used to be described as the workhouse and now is the county home. I should like to take this opportunity of congratulating the Red Cross, the Rehabilitation Society, the St. Vincent de Paul Society and other organisations who have led the way in this regard. By their own efforts and industry, they have tried to improve the situation. When one finds groups of people thinking on these lines, not alone in Donegal but throughout the country, surely that must be ample evidence for the Department of Health that it is time they took an interest in it. However, I suppose if the Department concern themselves about it at some future date, we must be thankful. It took the Fianna Fáil Party from 1953 to 1966 to discover that the 1953 Health Act was a mistake.

In conclusion let me say that when Dr. Browne, as Minister for Health, revolutionised the health services of this country in 1948 Fianna Fáil tried to class Dr. Browne as a communist. As a member of an inter-Party Government, Dr. Browne was a progressive thinking man. Under a Fianna Fáil Government, the Department of Health lay dormant from 1932 to 1948, and the only way they could cover up their mistakes was to try to appeal to the innermost thoughts of a Catholic nation and suggest that this new leader of the Department of Health was a communist from Moscow. It is only right that a Deputy not belonging to the Labour Party should refer to this and say that Dr. Browne set a headline for this country and particularly for the present Fianna Fáil Government. I am glad that at long last they have accepted that man's views and that they are on the way to accepting a "Just Society" which the Fine Gael Party advocated prior to the 1965 general election and which was received with protests by the Fianna Fáil Party in the early stages of the election campaign. They began to accept it during the campaign and they have now accepted 50 per cent of it. I hope when Germany presents them with the £7 million to cover up their blunders that they may think of accepting the other 50 per cent and really have a just society. I do not care whether it is Fianna Fáil, Labour or Fine Gael who bring that into operation as long as it is provided for a society that needs it.

On behalf of the Labour Party, I wish to put before the Minister the views we have been pressing on him and I want to congratulate him on accepting the pressures that we have been putting on him since he took up office. When I say "we", I mean we in the Labour Party in the Twenty Six Counties who have been speaking on this matter through the health authorities for years. We were the people who fragmented the Special Committee set up to inquire into the health services and presided over by the noble Parliamentary Secretary. We saw in that Committee nothing but a complete haggle between the Fianna Fáil and Fine Gael Parties without any regard for the suffering people.

It was the Labour Party who made the Minister for Health sit up and take notice. It was because of our actions and the threats we made when we introduced a motion in this House on the health services that left the Minister under no misapprehension about our attitude. We made him jump and sit up and take notice of what we said then. As a result, we have this rehash, this second edition of Aesop's Fables, put up before us for consideration, a rehash of the recommendations of Dr. Noel Browne carried on by us in the Labour Party. We advocated all this and more than is in this edition of Aesop.

We had the Minister for Health going around the country to dinners and dances and at crossroads propounding and talking about this great White Paper. He says that he will see that it is implemented but he does not say when because he knows that he has no intention of ever implementing some of the things he has in it. It is a smokescreen to divert the people's minds from the present critical economic position in which we find ourselves today. I know the Minister to be a wily man. I know how he can manoeuvre, but if he thinks that he can mislead the Labour Party and the people of Limerick, he had better start thinking again.

The Labour Party have been advocating the free choice of doctor and of hospitals since we came in here. We have been doing it through the health authorities all over the country. It is nothing new and there is no need for the Minister to be trumpeting and bellowing around the country about this garden of Eden, this Utopia which has been presented to the Labour Party. The proposals which he put before the House go only half the road as far as we are concerned. Written into every bit of it is the political intrigue at which the Minister is no amateur. Written into it also is his proposal to set up regional councils and take from the authority of the people all the things that matter and hand them over to the Minister.

I know that the Minister in his simplicity will give fair play to everybody. I know that he will see that justice is done all round and that he will not consider any of his friends for appointment to these boards and regional councils. Where are we going? Where does the Minister think he is going to lead us? We are not that foolish. We are not going to fall for this class of stuff in 1966. There are some admirable things in this document but there is nothing original in it. We have been advocating these things down through the years since we became organised as health authorities. The Minister has now adopted the recommendations made by us because of the experience we had in the operation of the Health Acts.

Some time ago, when I concluded the debate in the House on the Labour motion on health, I pointed out the injustices that exist because of the county boundaries. I instanced cases of people living two miles from the centre of the city of Limerick in the County Clare and who had to go 30 miles to the regional hospital in Clare instead of going to Limerick. I instanced a case of a woman who was not allowed into a hospital in Limerick and who had to go to Ennis. That woman died as she could not be brought to a hospital in time because of the ruthless administration by the county manager of the Health Act.

I congratulate the Minister on taking our advice in this matter of regionalising the services. It will make things more workable, more economic, and it will make for closer cooperation. What I object to is that the Minister, according to this document, will say who is to act on the boards and he is going to give outside people representation. Professional people, naturally enough, I suppose, will be included and are entitled to be included, but they are not entitled to vote on any matter of financial importance to the Board. We all know the reason why. That, however, has not been stated in this document by Mr. Aesop. I want to deal particularly with the administration of the Act as it concerns certain people in the community. I have in mind particularly the dental services which are at present partially available. My experience in Limerick has been that children get first preference, then TB cases are treated next——

Mr. O'Malley

The dental services in Limerick are the worst in Ireland.

I am glad the Minister said that. The Minister was a member of Limerick Health Authority long enough and what did he do about them?

Mr. O'Malley

That will get the Deputy nowhere.

It will not get the Minister anywhere, either. It will get me as far as it will get the Minister.

I am sure they are no worse in Limerick than in many other places.

We have a waiting list going back four, five or six years in Limerick and when we make representations, we are told: "You will be considered and you will have to wait your turn in the queue." Live horse and the grass will not grow any more. There is, however, an answer to this problem and I want to see the Minister taking his courage in his two hands in this matter. When you are in a position of responsibility, you must make the unpopular as well as the popular decisions, if you want to do the right thing. While this problem has been solved in other areas, no regard has been had to it by the Department of Health. Deputy Kyne, I am glad to say, mentioned it in his opening speech on behalf of the Labour Party. I cannot for the life of me see why a prosthetist, or a dental mechanic, if you like—a prosthetist is a man who serves his time at a three years course on the Continent—can come along——

You are mixing it up.

I am glad that I am educating some of the Fianna Fáil people who never heard of, or were never acquainted with such a service, but it is there, and I am sure the Minister knows all about it. These people are allowed to make impressions and if they are allowed to make impressions, surely they should be allowed to fit the dentures? But what happens is that the impression, when made, is handed over and the prosthetist, as he is properly called, gets only from £3.10.0. to £5 for the denture which he turns out. It is handed over to the dentist and then £20, £30 or £40 is charged for it. The Minister knows that, and it is happening in Limerick and in every other town. That is where our dental services fall down.

If we want to break up the queue of five or six years standing, we must be honest about it and if the supply cannot be met by what we have at the moment, and it cannot be done in the foreseeable future, we must tack our sails and apply ourselves to what can be done to relieve these unfortunate people. I am putting that case to the Minister as strongly as I can. It is a serious situation and there is no point in the Minister coming to me and saying that the dental services in Limerick are the worst in Ireland. That is not the answer. He told somebody else last week that Dublin Health Authority was the worst in the world and I suppose if Deputy Coogan speaks when I am finished, he will tell him something else.

Now I come to deal with the ophthalmic services. In Limerick, unfortunate people have to attend the hospital at 7 o'clock in the morning, if they require treatment. We have raised this question of the necessity of having more specialists to treat our children's eyes, time and again with the health authority. The Minister tells us that he is going to have discussions, that he is going to talk with the chemists and with the dentists and with everybody connected with the health services. Why did he not come in here and tell us:"I have done this; I have reached agreement on this and we can go on now."

Mr. O'Malley

Like the Free Trade Agreement.

Mr. O'Malley

You objected when we came in and told you what we had done. You cannot have it every way.

There is nothing free about the Free Trade Agreement. It is free as far as John Bull is concerned but not as far as John Farmer is concerned. He is tied to a figure and to a quota. The Minister must not have read anything about it. If that is the Minister's assessment of freedom, it is not mine.

I want now to refer to the dispensaries in the county. I have on occasion brought to the attention of our medical officer of health the condition of some of the dispensaries and I asked him to declare them unfit, unsafe and dangerous for people to stay in for any length of time. They are ratinfested, with windows broken, doors off hinges and unfortunate people are asked to come in and sit and wait in the cold until the doctor is free to come. The majority of doctors are giving good service. In every profession, there are delinquents and black sheep and that applies also to the medical profession and to my own, and, I am sure, to the Minister's. Taking the position by and large these men have given good service down the years. They have got out of bed at night and made all kinds of sacrifices and their last consideration was a pecuniary one. These are devoted men: they deserve much better than what they are getting, what they got and what the Minister will give them under this White Paper.

The Minister says he is going to abolish dispensaries in one paragraph and later says dispensaries can be bought and used by the doctors, for what purpose I do not know, because if the doctor is going to treat one section of patients in the old dispensary and the others in his own home, the whole scheme falls down. There can be no discrimination as far as we are concerned between one patient and another. Doctors must live: they go through a long university course of seven years or more, and specialists must go further still. They must be recompensed and treated accordingly. There is no use in treating them as the Minister's predecessor did like snuff at a wake, thrown here and there as he wished. I am glad the Minister has given so much consideration to the medical profession and consulted with them and with the chemists even though, as he admitted today, he has not yet reached agreement either in regard to the dispensing of drugs or the panels of doctors. Yet he asks us to give an all-clear to this scheme.

I speak on behalf of the Labour Party and, as far as we are concerned, he has the all-clear now. Let the Minister introduce the scheme now and we will vote for it straight away, providing he implements it immediately, which he has no intention of doing.

(South Tipperary): We shall be behind him.

If the Minister is honest about this, let him put it to the vote next week and we shall make it law in half an hour. That is how eager we are to see people getting a fair health service which they are not getting. We are not treating this lightly or as a smokescreen or a stalling tactic to keep people's minds off something else. We are serious because we know what is happening. We meet the people, live with them and know how they exist.

I want to mention the position of nurses, another section of the community who are dedicated people, not worried so much about the hours they spend at their jobs or the rewards they receive, but everybody here I am sure will agree that this section have not been treated fairly in this country. Not alone have they to do their ordinary duties but they have to attend classes and lectures. They must study in their spare time and in many cases they are asked to do the most menial work which is beneath their vocation and position but because of their calling and their devotion to it, they do it all ungrudgingly. If any section of the community needed uplift and toleration, it is the nursing profession. I know how hardened some matrons can be because of their frustrations and disappointments and one thing and another. They are in charge of these nurses and they act more like sergeant majors or Belsen Camp commandants than human beings. They make life intolerable for these young girls. The Minister has fallen down badly in providing——

(South Tipperary): The Deputy has lost six votes. There are six matrons in Limerick.

The Minister is welcome to them. I shall send them a personal letter such as he sent to everybody at the last general election and I shall tell them to vote for him. I am sorry the Minister has not improved the position of that section of the community. As a member of Limerick Health Authority, I know that we are swamped with applications for posts as trainee nurses year after year from girls with Leaving Certificates in most cases, who come from good homes and want to devote themselves to this work. We are lucky in Ireland, luckier still in Limerick, that that is the position, but it can be very easily reversed, if these people do not get the treatment to which they are entitled. I am surprised that the Minister, being a bit of a glamour boy himself, should not have thought of them and included them in the scheme or given them recognition in this White Paper.

I come now to the most unfortunate and distressed section of the community, the discards, the unfortunate people who are old and infirm and who are left to fend for themselves. The Minister knows this because he said it publicly that he had the experience on the one, and I suppose the only, time that he went into a church in Limerick—this is the Minister's statement—of seeing an unfortunate woman sitting inside the church door on a seat near the radiator. He asked her what she was doing there and she said: "I have no place else to go into out of the cold". The Minister said that at a public function in Limerick. We may laugh and joke about that but it could be any of our mothers. That is the tragic part of it. Where is the provision for such as these?

A band of charitable people have set out in Limerick under the Guild of St. Anne to build houses. They have collected money, tradesmen have come forward and given their time voluntarily to erect houses for some of these unfortunate people. Hardly a day of the week passes when I am at home that I have not two or three visits from people asking me to give them a note to the city home. They want to sleep there for the night. When they go there, they are regimented, nearly counted.

The Deputy is now discussing housing.

I am talking about old people and accommodation for old people. With all due respect, a Leas-Cheann Comhairle, I do not think you are paying attention. I am not doing the schoolmaster, now.

I understood the Deputy to be discussing old people who have no houses.

They go into the county home. Every day of the week I have visits from these people. This is a matter of urgency in Limerick because we have demolished the old dosshouses where these old people used to spend the night for a bob or a couple of bob. They walk the streets of the city during the day and when night comes, nowadays, as sure as not there is no room in the inn. They then have to walk the streets all night. The position is very serious. When they are taken into the institution, they have to get out of it by eight o'clock in the morning and have to walk the town all day. Then, at night, they must go to a home assistance officer or to a public representative to get a note allowing them in again. Surely, in this year of Our Lord, 1966, this is intolerable? It should not happen. What is the Minister for Health doing about it in his own town? I feel sure a similar situation exists throughout the country. These unfortunate discards are very close to me; they have my greatest sympathy. Every Monday morning they get £1 or 15/- from the home assistance officer and that has to do them for the week.

I am not quite sure whether the Minister is clear on what is in the White Paper or how much of it has been stolen from Labour Party policy. Is he clear on the implications? From statements he has made and from reports I have heard, I do not think he is. I ask him to take another look at the Labour Party policy. If he has not got it, I shall be glad to get him a copy. Then he can have another look at this Aesop document he has presented to the House. It is not what we can call Christian thinking, something about which we can say: "This is the best we can do: it is the best we can give the people." When he is replying to the debate, he will probably ask where he is to get the money. Has he not not answered that already? Has he not stated several times in the document "When times get better, when the economy improves"? It is written all over the document. He speaks about discussions taking place. It takes two to make a discussion. How does the Minister know discussions will take place? How does he know there will be agreement from the discussions?

I wish now to refer to the functions of the health authorities. The authorities are to be regionalised, according to the Minister. Is he to make the authority of these regional bodies the same as that of borough councils and urban councils? All they can do, all Limerick City Council can do, all pass recommendations and agree on a rate. I am afraid the Minister here wants to put the health authorities in the same boat. The regional authority for my area will comprise Counties Clare, North Tipperary and Limerick. Those of us who will be members will have to travel around and hold meetings once or twice a month. What is the purpose of that if the Minister hands over the functions of such an authority to the manager or to the CEO? Why establish such authorities at all? I have experience of this and of its humiliation.

I have been a member of Limerick Health Authority since it was founded. As a member, I have been turned away away from hospital gates, refused admission. I have been turned away from hospitals when I have called to see patients inside who had been asking for me. I have had to make complaints to the Minister and his Department. I want the functions of the new health authorities based on the same principle as the mental hospital boards whose members may go to the hospitals to visit patients at reasonable times. We do not wish to have to go along with our caps in our hands. If that is the type of function the Minister intends to give us in the newlyappointed health authorities, I wonder why I presented myself to the people of Limerick. I feel sure I speak for all the Labour Party on this issue.

I turn now to a much more important matter, the provision of this mercy mission that we have all read about and heard so much about—this helicopter service that we have been crying out for since 1948 not alone for the transport of urgent cases but for other purposes. I remember a case where two lads were cliff-bound off the Kerry coast. Had the helicopter service been available, those two lives would have been saved. The urgency of such a service was pressed on the Minister for Defence and eventually we got this service. The Minister and his photographers went out, a life was saved and that was that. There is nothing spectacular about all this—it is ordinary day to day routine. When the clamour is over, after the helicopter has arrived on the front lawn, the bill arrives.

I got one last week. They described it as a mercy mission.

When did that happen?

Last Saturday, in the Aran Islands.

It is not hatched yet; it is still in the incubator.

Who gave the authority to order the helicopter?

I did. The Deputy is in the same constituency but the people there do not know whether he is or not.

Hold it for the Oyster Festival next year.

Progress reported; Committee to sit again.
Top
Share