Dáil Éireann debate -
Wednesday, 30 Mar 1966

Vol. 222 No. 2

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 and Ard-Chláraitheora), and certain Services administered by that Office, including Grants to Local Authorities, miscellaneous Grants and a Grant-in-Aid.

—(Minister for Health.)

Mr. Treacy

This is unquestionably a very important Estimate which contains provision for some very substantial improvements in our health service. The Labour Party, naturally, are pleased about these improvements. Our concern now is to know, in so far as the Minister can indicate, when these improvements will take place. It has been indicated in the Minister's White Paper that it will be some years before the improvements are brought about. In the meantime, the people must continue to suffer under the archaic and outmoded Health Act, a Health Act ridden with an odious means test in respect of qualifications for a medical card, a Health Act which makes for anxiety and distress amongst the lower and middle income groups.

I am availing of this opportunity to appeal to the Minister, pending implementation of the proposed improvements, to be good enough to indicate to county managers and the various local authorities responsible for the health services that managers should have regard to the spirit and intention of the Minister's White Paper and the pending legislation and should liberalise the rigid means test which they are continuing to apply to the populace.

The improvements in respect of the lower income group are welcome. The lower income group comprises some 30 per cent of our people. They are now being conceded a choice of doctor. Heretofore, they had to endure the outmoded dispensary system whereby they were obliged to queue up for the dispensary doctor and in very many instances the numbers attending dispensaries were such that no doctor, however dedicated and sincere, could possibly give to each individual patient the attention he or she merited. Consequently there was a rather haphazard approach to the provision of health services in respect of the lower-income group. There was also the problem of the patient falling out with his doctor or losing confidence in the doctor. That unfortunate patient, who held a medical card, had no redress. If he did exercise a choice of doctor, he had to pay. To my knowledge, many holders of medical cards, in the lower-income group, have been continually exercising this choice of doctor rather than avail of the dispensary system and they are obliged to pay for it. The choice of doctor is welcome and it is long overdue.

The only other improvement in regard to the lower-income group is in respect of the maternity cash grants which are being increased from £4 to £8. The most important aspect of the pending legislation is that it will clearly define the categories of persons who are designated as being in the lower, middle and higher income groups. Up to now the situation was ambiguous. The administration was vague and unjust. An incomes test was never applied in the strict sense in respect of who was entitled to be placed on the medical register and entitled to a medical card. All that the law stipulated was, to quote the Act, that any person who through his own industry or other lawful means was unable to provide a health service for himself or his dependants was entitled to be placed on the medical register and be conceded a medical card. That kind of vague generalisation could clearly be interpreted in a thousand different ways. The kind of test which was applied varied from health authority to health authority and each different county manager applied a different test.

One of the tests applied was that the manager would take the wage rate of some of the lowest paid workers and use it as a yardstick as to who would get a medical card. He would take the rate for the agricultural worker, a county council worker, or a forestry worker, and reckon that that then would be the test—say, £8 for a husband and wife, and he would conceivably add 10/- for each child. He might also take into account the rent being paid for the house. Clearly a large proportion of our working-class people were excluded from getting medical cards by such tests—industrial workers, tradesmen and artisans who earned more than £8 or so a week, and which of course would provide only a substandard level of existence for a family. I am very glad that the Minister now proposes to define clearly who will be entitled to a medical card.

There was also the humiliating and distressing aspect involved in this means test. At any time a means test is embarrassing and humiliating as it involves a prying and probing into the private affairs of a family. The tests in these instances are carried out by home assistance officers. I do not wish to reflect on the worth of these people, but, in my opinion, home assistance officers are not fit persons to carry out a test of this kind. If there is to be a means test under the proposed legislation, I would ask the Minister to introduce some other means by which the necessary information can be gathered without having home assistance officers calling to the homes of decent people and not merely securing the information there but also securing it from neighbours and accepting it as factual and truthful. Some of these men are honourable and are doing their job conscientiously. Others, it seems to me and to my colleagues are prejudiced in many ways. They are prejudiced in regard to class and status and unfortunately sometimes there is political prejudice as well. We have seen injustices in many cases.

These gentlemen provide assistance for the most destitute and helpless section of our society and their prime function is to dole out assistance to those who are in dire need. Everyone knows the test applied in regard to the provision of home assistance must, of necessity, be rigorous. Many of these men are influenced by the low standard of life of the people with whom they deal most. Unfortunately, they bring this prejudice to the homes of decent working classes. I have said that they are prejudiced in respect of class and I said this because we have known them to take it upon themselves to say to an applicant, who might have requested an appropriate form for a medical card, that he was not entitled to a card and they would not consent to put that application through the proper channels in order that a proper investigation could be held and in order that the county manager, the final arbiter under the Minister, could make a decision.

It is also a well known fact that if they see any signs of comfort or decent living standards in a home, if they see such things as a radio or television set, the applicant will be automatically ruled out. These are no longer luxuries but everyday appliances which are to be found in the homes of all progressive people. Likewise a car is an essential means of securing a living for most of our people today. The fact that these things should be in any of these homes would seem to put paid to the possibility of their owners getting a medical card.

The people of this country have been indignant and will continue to be indignant until this odious means test is done away with. It is not sufficient to know that these categories of people will be clearly defined. We want, above all else, a more humane, respectful and understanding approach by the people who will be defining them. If there is to be a test, let that test be carried out with due regard to the dignity of the human person and the responsibilities of family life.

One of the most serious defects in the White Paper is that there is not much improvement in it so far as the middle income group are concerned. They are the people who have suffered most under the present Health Act. They are excluded from free medical attention and have to pay all. Many are borderline cases who could not provide the fees for doctors and specialists, for hospitalisation and for costly drugs and medicines. Through lack of means many were obliged to defer urgent medical attention, and it is my opinion that many of them have gone to their reward before their time because these facilities were not made available to them without £.s.d.

In the White Paper certain concessions for the middle income group are proposed. They comprise the biggest section of our community, 55 per cent. The only concession they are getting is the possibility of free drugs and medicines, where they can prove there is an illness of a prolonged and costly nature in the household. That is not good enough, and I sincerely hope the Minister will see fit to extend to a large proportion, if not all, of the middle-income group the same conditions as are accorded to the lower-income group. It is all right to say in the White Paper that the middle-income group will be assisted in respect of the cost of hearing aids, spectacles and dental treatment, that the question of hospital fees may be looked into and possibly reduced and that they may get free drugs and medicine, if they can prove their case. But surely it is degrading that these people must beg for these concessions or solicit the support of their local representatives or TDs in order to secure some amelioration of the hardships imposed on them by illness?

When the previous Minister for Health announced this concession in respect of free drugs and medicine for those unable to provide them, it was disconcerting to realise that many of the health authorities concealed this information from the public. Whether that was deliberate or not I do not know. Certainly, the public representatives knew it, but it was only by means of Dáil Questions we succeeded in getting across to the public that this concession was there for them. Whatever concessions are conceded now, I hope the Minister will not allow this to happen again.

I believe the Minister is courageous and progressive. He is certainly working along Labour lines. We will support him enthusiastically so long as he carries out our wishes in respect of these matters. I think he is sufficiently courageous to stand up to any vested interests who might seek to hinder or impede him in the implementation of progressive legislation of this kind. I feel certain he will not allow any vested interests, be they in the managers' association or in the medical profession, to conceal or withhold from the public the concessions there at present and those which we hope will be there in greater abundance when this legislation is enacted.

It is true also that many people now regarded as in the higher income group are suffering great hardship and privation trying to meet medical costs. Those of us in public life have been appalled at being shown by men and women in high station, with what might be considered very good salaries, colossal bills for hospitalisation, specialists' and doctors' fees and for specialist appliances. These people are virtually beggared by the cost of remaining reasonably well in this country. I want to see concessions for them as well. A medical service should be available for all, irrespective of their status or of their salary scales. In applying tests of this kind, it is not good enough to talk in terms of income alone, because one has to know intimately the domestic affairs of the families concerned. I sincerely hope, when the Minister is laying down these new demarcation lines between the three categories, lower, middle and higher-income groups, that the higher-income group, which now comprise some 15 per cent of our people, will be reduced considerably, down to at least ten per cent so that a greater number can be taken into the middle-income group and given some concessions in respect of the health services.

The Minister may say to me it would not be justified at the present time. The Minister will realise that neglect of this kind in regard to health must be met by someone. If it is not met in part by the State, it must be met entirely by the individual. The only concession at the present time to this category of persons is that they may get a subvention from the local authority for their maintenance in a local private hospital. Unfortunately, as the Minister will realise, the subvention to which I have referred, a sum of 22/6 per day for the maintenance of the patient in a private hospital, is for a limited period of time only. County managers usually stipulate a period of some six weeks. They are humane enough to extend that period for another six weeks, making it 12 weeks, but it is extremely difficult to have this concession granted for a further period. Clearly six to 12 weeks is not a reasonably sufficient period of time to permit of a full recovery to health.

There are a few more aspects of the health services to which I wish to advert in the hope that the Minister may see fit to include these suggestions in his amending legislation when it comes before the House. The school inspection services we have at the present time are not adequate. These school inspections are not carried out often enough to take proper care of the children in our schools. The inspections, in many instances, are carried out in such a haphazard and indifferent way that some parents have become prejudiced against the service. It is lamentable to realise that while we provide a health service in respect of children attending national schools, the children who go to a secondary or vocational schools are not provided with such a service. The service stops at the national school. Apart altogether from the fact that the children have this service while attending national schools, their parents may also possess medical cards.

I am asking the Minister to take steps to ensure that the health service will be extended to cover all children, irrespective of class or creed, and that it will take care of them in all categories of schools. I am sure the Minister will not allow class-distinction to enter into this matter or the prejudice of certain schools or managers. It is quite a hardship on the parents of the middle-income group and some parents in the so-called higher-income group to provide the high fees to send children to these places of higher education without having to meet the recurring cost of dealing with their health as well. Many people have adverted to this problem, and many people are looking now to the Minister for Health to ensure that this anomaly in the health service which has lasted too long will be rectified in the present code of legislation.

It is also true to say that chiropody treatment is not provided in the health service, even for those who are holders of medical cards and allegedly entitled to free medical services of all kinds. If I am incorrect in that statement, the Minister may pull me up here and now. It is my experience that chiropody treatment, which is of such importance to the aged, is not provided for them. Many of these old people, perhaps living on the old age pension or the widow's pension or some small sickness benefit, even though holders of medical cards, are obliged to pay a chiropodist when they require to have ailments of the foot attended to, and ailments of the foot become progressively more pronounced as one gets older. It is a serious handicap to a person in old age if such ailments cannot be attended to, and these have often resulted in lameness and inability to get out and about at all. I want the Minister to have a look at that matter also.

The problem of the mentally and physically retarded in our society is one which I hope is activating the mind of the Minister and his Department. This is surely the Cinderella of the health services. It is saddening to realise that on the waiting list of every health authority there are large numbers of mentally and physically retarded children for whom we cannot provide proper institutional treatment. I appreciate that providing specialist staff and bed accommodation in the proper institutions is a problem, but it is one I cannot pass over lightly.

It is a scandalous state of affairs that we have these children domiciled in their own homes, a source of great worry, anxiety and distress to their parents. That is particularly true in the case of the mentally retarded who have been kept waiting for seven or eight years on the lists of local authorities and as yet no bed facilities have been provided for them. The Minister for Health is fully aware of the plight of our health services. I sincerely hope he is taking all the necessary steps to ensure that institutional treatment will be speedily forthcoming for these categories in our society.

Despite his difficulty in securing the necessary finance to meet the cost of all his proposals, I would appeal to him to make this top priority so that physically disabled and mentally retarded children can be properly institutionalised. It is not good enough to leave them to their parents. I am aware, and so are others, of the serious burden these children can constitute. They can be a danger to other young children in the family. Despite repeated requests, local authorities have done nothing to provide the proper treatment. Were it not for the good work done by religious, the situation would be infinitely worse and a deep debt of gratitude is due to these religious for the care and devotion they lavish on these unfortunate children. Theirs is a vocation, but the State also has a responsibility and the State must shoulder that responsibility now and ensure that the problem is dealt with as a matter of grave urgency.

Another problem is the inadequacy of the present health services where old age is concerned. It is sad to realise that when one becomes old, no one seems to want one. That is true of families and it is also true of our health services. It is becoming more and more difficult to obtain accommodation for the aged in local hospitals and, if the accommodation is forthcoming, the treatment will be of short duration. The aged are promptly discharged and returned to their families. We know the difficulties of families in trying to care for them. Many of them are tough nursing problems. If it were nursing alone, families would try to provide it, but the question of geriatrics also enters into the picture.

There are the chronically sick, those suffering from incurable diseases, cancer cases; in every case there is a reluctance to provide beds for these in local hospitals. If beds are provided, one can be assured, as I said, the stay will be of short duration. The alternative is to transfer them to the county homes. That is just not good enough. Decent old people should not be discarded in that fashion. Treating the diseased in that fashion is to be deplored.

I should like to see a certain number of beds made available in all local hospitals for these people. I should like to see a geriatric ward provided for the care of the aged and incurable. It is not good enough to say there is accommodation for these in the county home. I do not wish to cast any aspersions on county homes. I am familiar with many of them. They are doing excellent work. They have been vastly improved. They have been modernised. They provide excellent health services. It is a well-known fact, however, that Irish people have an ingrained prejudice against going into county homes. Call them what you like, after saint or patriot, the people do not like them. It matters not a damn what they are called. Their origins were in the poorhouses of 150 years ago when our people suffered under oppressive foreign rule and countless thousands —millions—were denied the means of livelihood, rendered destitute and poverty-stricken. The poorhouses were erected for no other purpose except to maintain life at the lowest level. There are many decent people who would prefer to die at home, or die in any other circumstances, rather than go into these county homes.

An alternative must be found. I should like to see a home for the aged in all our important towns where these old people will be in their own environment, close to their families and friends, where they could have frequent visits from these friends and relations, and where the local community could take a continued interest in their welfare. This is a serious blemish on our health service, this disgraceful way in which we treat our old people.

I have already referred to incurables. Unfortunately many young people do fall victim to malignant diseases. When this becomes known in the hospitals, these young people are discarded and sent back to their own homes. Then you have the serious problem of the family trying to deal with what may be a cancerous case, or with a person suffering from some other malignant disease, and the family is not equipped to do this. This is not a case of nursing; this is a case of proper hospitalisation and proper medical attention. Such a case may require the use of strong drugs, the giving of injections and dressings and other matters which the family could not be expected to do. In these circumstances, it is reasonable to suggest that there should be proper hospitalisation for these people.

Pending the realisation of the ideal of homes for the aged in each local area, I have suggested that there ought to be a number of beds reserved in a geriatric ward where these people would be entitled to go by right. The present situation is extremely bad. I know it to be particularly bad in some parts of the country and if that extends throughout the whole country, it is a serious blemish on our society.

There is not much more I wish to say. I am sorry the Minister was obliged to leave the House as I have one or two compelling matters to bring to his notice but I think I have said sufficient to call attention to what I consider to be the weakness in our present health services and the inadequacy of the proposed legislation. I do not think that any Party in this House can claim very much credit for improvements in our health services. These services were probably the worst in Europe and any improvements in them that are proposed or have come about have come through no great willingness on the part of the Government Party. These meagre improvements have come about as a result of a vast volume of public indignation in this country crying out against these rotten health services.

This Health Act must have lost Fianna Fáil a considerable number of votes in recent elections. Public indignation has forced the Government to give these concessions, which are not sufficient as far as the Labour Party are concerned. We want to see a health service for all our people, irrespective of class or creed, not as a charity but as a fundamental right. Our people are prepared to pay for such a service in proportion to their ability to do so. We want to see a health service on an insurance basis similar to the health service in Britain, under which all our people will be catered for, lower, middle and higher income groups, farmers, workers and business men. We have not got that. We will keep on agitating until we get it.

This Estimate has been lauded as a real mark of progress by some political pundits. It is well to reflect on the struggles carried on inside and outside this House for improvement in our health services over many years and I avail of this opportunity of saluting the brave, courageous and progressive men who agitated in this House for a decent health service for our people. I have in mind particularly Dr. Browne who, unfortunately, is not with us.

As Minister for Health, Dr. Browne achieved a lot in a short time in office. To him belongs the great credit for the mother and child welfare scheme. He would have done very much more if he had got support from this House. In 1956-57 as a Minister for Health supported by the Labour Party, he would have given our people a health service far in advance of the present lauded legislation. However, his proposals were doomed to disaster at that time and it is ironical to think that what was outlawed as immoral and illegal at that time is moral and legal now. It is difficult to understand that his proposals at that time were deemed to be of such a controversial nature that they brought down a Government. Many of the things he wanted to do then are being done now and there is not a tittle about it. I congratulate all these brave men who pioneered this legislation and made it possible for us to talk in terms of improvements in the health services and improvements which, it seems, will be coming into law without frustration of any kind from any section of our community.

My concern is, as I said in my earlier remarks, that much political capital has been made out of these improvements. The Minister has had his share of publicity in the press, on the radio and particularly on television. It has been conveyed to the people that these improvements are being made but, unfortunately, it has not been brought home forcefully enough to the people —and probably this is deliberate— that these proposed improvements will not be implemented for some years, certainly not for two to two and a half years to come. With the present state of our economy and the added revenue required, I sincerely hope that it will be found possible to do these things in that time. One becomes anxious and concerned when we see that the financial resources of our country are becoming more and more limited. When we see a very limited cut-back on essential services, especially housing, we wonder if the Minister for Health will be in a position to secure the additional financial aid he requires to implement this legislation. We sincerely hope he will. We shall certainly support him in that aim.

I want to advert briefly to my earlier remarks and to appeal to the Minister —however long or short it may be before this legislation becomes law and the people can avail of it—to advise those people who are administering the Health Act at the present time to lift the dead hand from it. They should be told to be more liberal, more humane and more understanding of the needs of our people and to ease and liberalise this odious means test, in respect of who shall get a medical card, which they are still applying. It is important that the facilities for free drugs and medicines, the subvention for maintenance in private homes, and all these other matters are made known to our people so that they may avail of them and so that they are not withheld or cloaked from our people by any of the vested interests involved.

The Minister has probably missed a considerable amount of my speech but I hope he will read it. I wish him every success in implementing these proposals, and implementing them speedily. I hope he will do the things which we in the Labour Party would like to do and which, please God, we shall be given the opportunity to do in this country as the peoples of other near nationalities have been granted in recent times.

Mr. Lindsay

I want to make a few brief references on this Estimate and, as I understand it, on the White Paper which we are supposed to be discussing as well. Let me say at the very beginning that any discussion on health, in circumstances such as these —on an Estimate which makes no extra provision of any significant kind for the future and a White Paper that does not tell us how future health plans will be financed and neither the Estimate nor the White Paper being accompanied by any kind of logical proposals—must be of a speculative nature.

Apart from the fact that the White Paper ignores the method of payment, it is, by and large, the policy of the just society enunciated by the Fine Gael Party prior to the last general election. We base our health policy on insurance, too—one-third Government, one-third employer and one-third employee, that is, above a certain level. One has only to look at the success of the Voluntary Health Insurance Scheme, conceived and designed by Deputy T.F. O'Higgins, to understand how fundamental is this policy of insurance in the matter of provision for the rainy day, not alone in respect of health but in respect of several other matters in our daily lives. In passing, now that it has been a considerable time in existence, I think one must compliment the Voluntary Health Insurance Board and their employees on the manner in which they conduct their business and the helpful nature of their attention to the problems of people insured with them.

Outside the realm of the confessional, there is, to my mind, no more sacred and secret relationship, based on mutual confidence, than that between the patient and the family doctor —and the family doctor can acquire that particular name only when there is a choice of doctor. Our plan included a choice of doctor, which now appears about to be adopted. I regret the awkwardness of the future participles but future participles appear to figure very largely in these proposals for health.

I do not propose for one moment to denigrate the efforts or the intentions of the Minister for Health but I must point out that the White Paper was introduced at a time when there was not any money to implement the proposals contained in it. Furthermore, there is not any money now to do anything about it. On the Minister's admission, it is not likely that anything of a significant nature will happen in this respect until the end of 1967. One cannot, therefore, regard this effusion as anything more than an enthusiastic effort to bypass the immediate and pressing problems that beset us. Health is something in the lives of the people not alone here but in any other country which cannot be and must not be made the plaything of politics. Human life and suffering are much too important to fall into that category and when the legislation comes in, with Deputy Treacy, I hope the categorisation of classes of people will be so clear that it will be taken entirely out of the realm of interference by politicians of all Parties.

I know of cases in the administration of the Health Act where people who were perfectly well able to pay under existing conditions but who because they had the ear of the county manager, were able to get, in one instance that I know of, a hospital bill of some hundreds of pounds paid in respect of a patient who died and whose estate subsequently realised thousands. That is how money can be diverted from the really deserving to the undeserving who happen to have the ear of the right people at the right time. If we are to have categorisation, let it be done well, but it will not be easy to do that, having regard to the different kinds of terrain, different types of valuations and different sets of circumstances that go to make up the incomes of families in different areas.

There is one classification, of course, which must be made immediately and that is a distinction must be drawn between illnesses of an instant nature that are curable within a certain time and those illnesses that become chronic. There are not enough beds in our county hospitals and there is often difficulty in getting beds in private hospitals when these are urgently needed to care for people as they should be cared for and of necessity, people have to be brought or sent home probably a little earlier than if there was room for them.

While I would be as concerned as any Member of the House with the old people, I do not share the view expressed that our people are anxious to get rid of the old members of the family and put them in institutions like county homes. You will find that where there is a family, whether a married son or daughter, the old person is not in the county home. The old person is either left alone in the world probably as a result of emigration or of the deaths of members of the family or for some reason associated with inability to get on with in-laws. These are rather isolated instances, as, in my part of the country at least, I can truly say the care of the old is a paramount concern of the younger members of the family and the attention and kindness meted out to them must be seen to be believed. I believe that is something that comes through paternal transmission at a time when the old people were young and dealing with their children.

I can give no better example of what I am trying to state than to recite a true story. Recently I was sympathising with a widow on the death of her husband. A very old woman in her eighties and her husband almost ninety, they had given up their own house and had been able to travel around and stay with three married daughters whenever they liked and as long as they liked. In the course of conversation, I said: "You were very lucky to be able to move around and stay with the different daughters and their families.""Yes," she said, "we expected that because we gave them a lot of loving." That is where it comes in. There must be that paternal transmission to the young which will be remembered as they grow up and in turn, given back to the old people at the right time.

I have no fears, generally speaking, about the care of the old but I have fears about the old who live alone and whose means are not as great as they might be or as we would all desire, but I subscribe to the view of Deputy Treacy that, particularly in the big counties like Mayo or Galway, Cork or Donegal that are rather scattered, and even Deputy Treacy's county of Tipperary, the county home is not the place to bring people from distances of 50, 60 or 70 miles and put them into strange surroundings with strange people. There are many houses big enough but not too big which could be run by a housekeeper and visiting medical attention would be sufficient, where people could be visited by their own families and within easy reach, if they are distant relatives or if for any other reason, they must be kept in a house of this kind. By and large, I have no fear that our people will treat the old in any shameful fashion; I have far more faith in them than that.

I notice in the White Paper that it is intended to publish another White Paper on mentally retarded children. I do not think that can come soon enough and give us all an opportunity of discussing this terribly pressing problem. Again I subscribe to the view already expressed that were it not for the religious orders who devote themselves entirely to the care of these people, I do not know what would happen because we are in no way equipped to look after them. In addition, we have the voluntary organisations outside the religious orders who give their time and money with a generosity unsurpassed in very many fields where generosity is to be expected.

I see that the Minister for Health recently met the nurses, or some of them, and they seemed to have got on very well together. He seemed to think very highly of them and from what I can gather, they think very highly of him. The way to deal with that situation is to see that nurses have proper hours and proper remuneration. A nurse's life is extremely difficult, as is a doctor's, particularly a country doctor's or possibly a doctor's in the less well-off areas of the cities and towns. They are at beck and call day and night. It is really a dedicated service, with no nine to five business. That is something that should be always appreciated not only by the people but by the legislators when it comes to dealing with these matters.

I think the Minister is interested in the ambulance service. This is a service worth examination. Certainly, I do not understand the system that enables people in small local hospitals to employ hackney cars keeping the ambulances there idle and standing by and saying that that is good economics. I do not know whether it is or not. I cannot subscribe to the view that it is.

Every Deputy, I suppose, is entitled to become a little bit parochial in a matter like this. The Minister has not visited my constituency but he has been skirmishing Castlebar recently at a Press dinner and promised some considerable amenities. I suppose I may speak for Castlebar hospital. It needs to be enlarged and something should be done about appointing an assistant or two assistant surgeons. It amazes me each time I see Dr. Bresnihan, the county surgeon, that he continues to be in good health and to look well, in spite of the enormous burden of work and responsibility that has been falling on his shoulders over very many years.

We want X-ray and operating facilities of a minor character in Ballina. Deputy MacEntee, when Minister for Health, told me on one occasion that the cost of providing them would not be justified. I hope that when the present Minister gets money, he will do something about them. I hope money will be got soon, although things do not look so good. In any event, if we may, temporarily, heed the exhortations of the Minister for Finance to forget about the gloom, may I look forward to a future in which health will be taken out of politics, full and adequate consideration will be given to every category requiring separate attention in the provisions of the new legislation which it is proposed to bring in; a White Paper on mental handicap will be produced with all speed, so that we may discuss it, and then we can get down to business and be realistic about the whole matter? Above all, it is necessary to take health out of the realm of politics because it is awful that TDs, Senators, county councillors and urban councillors should be dependent upon votes or pretend that they are depending upon votes by again pretending to people that they are in a position to do something for them when it should be the fundamental right of the people to have these amenities and to have their health problems looked after in a proper manner.

I wish the Minister well in regard to his intentions. Certainly, as far as this Party are concerned, we shall give him every possible co-operation in order to bring about the situation which we envisage in our health policy as contained in the document, Towards a Just Society.

Mr. Larkin

While Deputies wish the Minister well so far as his proposals in the White Paper are concerned, particularly if there is any possibility of these proposals becoming operative in the reasonably near future and while we all agree in this House that the provision of adequate health services should not be a subject of Party political claim or advantage, it is no harm to set the record right in that regard. It appears from reading the White Paper and from a perusal of an earlier document issued by Fine Gael that both Fine Gael and the Government have, in fact, paid the Labour Party the very great tribute of taking over Labour's policy on health, as published prior to the issue of either of these documents.

While again wishing the Minister success while he remains in that office in having improvements brought about in the health services, it is necessary, for the purpose of the record, to refer to the contribution made by Deputy Kyne as the principal spokesman for the Labour Party in the Select Committee on Health Services which was appointed by the previous Dáil. After prolonged and frustrating experience on the part of Deputy Kyne and his fellow members of the impossibility of getting the then Minister for Health to accept the point of view put forward on behalf of the Labour Party, they were compelled to make their protest by withdrawing from that Select Committee. I hope the advent of the new Minister for Health and the publication of the White Paper will mean not just a theoretical departure from the approach of the previous Minister for Health but a complete and practical departure.

The Minister is a very capable man and all Deputies recognise him as being a competent man in many respects. He has already got an amount of credit for his action taken very recently in advising the various health and rating authorities that as far as the estimates of those authorities for health services are concerned, in certain circumstances the Minister would be responsible for any expenditure in excess of that for the year 1965-66. This decision, of course, had an effect on the demands which the various local authorities would be serving on the ratepayers.

The Minister has got adequate recognition for this action but, of course, this action of the Minister, while admirable from one point of view, is reflected in the general Estimates and at this point in time—we do not know what will happen in the coming year—there has been a very serious increase in the Estimates passed by this House. There has been an increase in taxation and we did notice at the time the Minister made his announcement that reference was made to the question of some system of equalisation of rates.

It was not quite clear what was meant but there is a certain amount of nervousness, particularly in areas which I represent as a Deputy and possibly in areas represented by some of my colleagues, as to whether, in fact, this may mean just a shifting of a burden from one section or part of the country to people whom we as Deputies represent. It was not quite clear what the situation would be. However, if these matters do not come out clearly in the Minister's reply to this debate, they possibly will come out in the course of the months that lie ahead.

There is one matter, amongst others, which requires attention, that is, the cost of medicines for the normal member of our community. Those in possession of a white card may be covered in this regard but there are thousands of families who have suffered very heavy increases in their normal domestic expenditure because of the cost of medicines and drugs.

Nowadays, anybody who contracts influenza or bronchitis or some such illness and who goes to a doctor and gets a prescription for tablets or for a bottle of medicine will find that it will cost him £2 or £3 just for one week's supply. Usually the dose for tablets is four a day, or a tablet to be taken every four hours, and the prescription covers about three or four days. If the illness does not clear up, he has to go back to the chemist with another prescription and it is another 30/- or £2. Those who are not specifically covered in this regard will either have to pay out this amount from their wages or salary or make a pilgrimage to their nearest Deputy or local representative to have him make a case for them. I was glad to hear at least one Fine Gael Deputy talking about this undesirable exercise of public representatives having to go to the city manager or the chief executive officer or some representative of the health authority to make a case for the particular person.

I do not think any Deputy will disagree with me when I say that no one who requires medicine, irrespective of the section of the community from which he comes, should have to go through this process of bearing this financial burden or having somebody make a case for him. This is all too common in city areas. Whether we like it or not, there will be, in some of the rural areas, a closer contact between the health authority and the person's family circumstances. In the city areas there are thousands of families endeavouring to pay for their houses, with all that that entails, and they have either to put up with economic hardships or get their local representative to make a case for them.

In regard to institutional treatment, there is no doubt that any person who requires such treatment should have the right to it, without having to bear any direct charge in a hospital. These matters may be covered in the White Paper but by the time the provisions of the White Paper become law, there will be many thousands of families who have suffered hardship in the meantime. Therefore there should be some immediate effort to do something in regard to the problems I have mentioned, the cost of medicines and hospital treatment.

While I am on the subject of institutional treatment, I want to refer to another aspect, that is, the increasing tendency, possibly because of a shortage of beds, to put people out of hospital on the grounds that the beds are needed urgently. There have been cases of people who have undergone serious operations who have been discharged four or five days later. Of course, if they had been in a semiprivate or private ward, possibly they would not have been so discharged. However, in the normal public wards in the voluntary hospitals, this practice appears to be increasing.

I have no doubt that the surgeon in charge may take responsibility but I am afraid that there is pressure on the medical officers to discharge the patients earlier than perhaps they should be. It has been noted in the city in regard to maternity cases that a woman who has given birth to a baby will be discharged on the fifth day. If that woman is in a position to go to a nursing home and pay the fees there, then in nine out of ten cases she will be kept in for a longer period.

I wonder if the Minister will ascertain whether, in the case of discharge from voluntary hospitals in city areas of women with new-born babies, there is any inquiry about their home circumstances, whether they are such that these women will be looked after when they return home, or whether because they are home, they will have to take up their full domestic duties again as housewives. We in this country often express our admiration, respect and love for our mothers but it appears to me that sometimes we do not practise what we preach. Anyone who has any knowledge in regard to the large percentage of local authority dwellings, particularly in the cities, must be aware that basically because of the cost these dwellings are kept to minimum standards from the point of view of the number and size of rooms. The statistics show that the average family in this country is much larger than the average family across the water. Yet in Dublin thousands of dwellings consisting of only three or four rooms are occupied by families with three or four children.

Do the authorities in the maternity hospitals ever consider the problem confronting a mother with a new-born baby who arrives home to a house that is not adequate by ordinary standards and is required to take up full domestic duties immediately? These are matters in which the Minister should show an interest. It appears that not much interest has been taken in them for some years past. I recall the Minister's predecessor saying on one occasion that, in his view, mothers should not bear their babies in maternity hospitals. I have no doubt that his home was reasonably large and had reasonable facilities. But he was not talking about the people in his income group, who can have their children at home or in private nursing homes as they desire. He was referring to the normal young mother living in fairly difficult circumstances.

There is another aspect of the health services that intrigues me. The White Paper indicates a number of desirable things. But before we can have a firstclass health service, apart from the question of money—which is in short supply at present—apart from the hospitals, apart even from the doctors, the question of the nursing and ancillary staffs in all our hospitals, both voluntary and local authority, must be considered. The Minister must be aware of the widespread dissatisfaction among nursing and ancillary personnel with regard to their salaries and conditions.

Let me instance one or two anomalies existing at present. In the Civil Service and the local authority service, there are salary scales for various grades of officers. The clerical officer in the employment of a local authority, whether employed in Dublin, Cork, Limerick or some small town, is paid the salary appropriate to a clerical officer. The nurses and doctors are also paid salary scales applicable to them. But when we come to other people employed in these hospitals, we find a form of distinction. I do not know whether I should call it class distinction or not. That may be as good a word as any. In Wexford, a fairly prosperous county by all accounts—I do not know whether this applies to Waterford, but if it does not, I know Deputy Kyne will pull me up— in many of the counties in the west, the south and the midlands, the porters in local authority institutions are paid £2 or £3 a week less than their counterparts in Dublin and Cork—and we do not say that the wage rates in those places are anything to boast about.

In a number of these hospitals, there are male attendants who look after the geriatric cases. Their wages in very few cases are in excess of the agricultural labourer rate. In some cases there are people with a wage of £7 or £8 10s. a week, while their opposite numbers in Dublin are being paid £2 or £3 more. If a clerical officer down the country is paid at the same rate as a clerical officer in Dublin, how can we justify paying these people £3 a week less than their counterparts in Dublin, although they work the same hours in the same onerous conditions? Part of the answer may lie with that esteemed body, the City and County Managers' Association. However, the Minister is responsible to this House for the health services. I am sure he is concerned that because of the existence of this kind of thing there is dissatisfaction in the various hospitals.

Deputy Lindsay referred to the dissatisfaction in regard to the working hours of nurses. That is quite true. Various organisations which represent them have applications in to remedy the position. Nevertheless, the situation existing in respect of the nursing personnel in these institutions, the attendant personnel and the most depressed class of all, and without whom none of these institutions can function reasonably well, must be considered. I refer to the domestics whose hours are very often 90 hours a fortnight, 45 hours a week, spread over a seven-day week. Surely the Minister would not be averse to conveying in his inimitable style, quietly and definitely, to the county managers concerned that this is a situation that could bear examination. If it is proper—and it is proper— for clerical workers, industrial workers, commercial workers and, I think, medical workers, except when they are called out in an emergency, to operate on the basis of a five-day week, these people who are concerned with looking after the ill, looking after the aged and the mentally ill, should get a square deal. A rate of pay of £8 for an attendant who has such onerous duties in caring for geriatric cases, a rate which is £2 or £2 10s. a week less than the current rate, is surely inequitable.

I am a Dublin Deputy but I am saying this to the Minister because I am concerned about health services. No scheme of health services, institutional services, no matter how perfectly designed, has any hope of serving the needs of our people adequately and properly unless the people who spend their lives in these institutions at that work are treated as human beings and paid adequate remuneration for their efforts.

In regard to the aged, a joint committee has been established recently in this city representing the various voluntary bodies concerned with old people. The problem of the aged is a growing one. The percentage of people over 60 years of age is increasing fairly steadily. It will continue to grow due, to a great extent, to the advances in medical science and to some extent, in spite of all the efforts, to some small advance in regard to standards of housing, the standard of living, and so on.

I doubt, however, whether the establishment of large institutions provides any satisfactory answer. Except for people who may need to be treated for acute sickness in an institution where the most modern operating theatre and highly qualified doctors are available, we should have another look at this problem of institutions for the aged. One of the difficulties for the aged is that they are lonely. They are not less lonely if they are in an institution where 40, 50 or even up to 100 people are kept in two or three wards.

I subscribe to what Deputy Lindsay has said, that, by and large, the members of the community would be happy to look after their parents in their own home. There are exceptions to that, but as their families grow up, many people would be quite happy and willing to contribute as far as they could. There are a number of practical difficulties. As people get old, they sometimes become a little difficult to deal with. When people reach 65 or 70 years of age, they do not, of necessity, become more equable in temperament or more patient. When they become increasingly subject to rheumatism and various other ailments, which are very wearing on the nerves of the average person, it may be a source of annoyance to them if four or five children, who naturally want freedom to exercise themselves, are making noise and jumping around. There is this problem in the small dwelling.

There is also the very difficult problem of finance. While it is true that pensions have been adjusted, many men and women with growing families who are willing to look after their parents find it is going to be at an economic sacrifice. In his examination of this problem, perhaps the Minister would consider the possibility of making an allowance in such cases. This would be good economics. Every old person who is maintained at home by a son or daughter and who would otherwise be in an institution saves the State a considerable amount of money.

The living conditions in the county home are almost at the minimum. It means minimum meals, a bed, maybe a bed with 20 or 25 other people in the one room. Sometimes the room is painted but very frequently there is not a very cheerful atmosphere. It means that when they are visited by their families, the visit takes place in the presence of other patients and other visitors in the ward if they happen to be bed patients. The cost comes to at least £12 per week. Some of them may be reasonably happy but many are neither happy nor comfortable. From the point of view of a social and human approach, it would be good business to think in terms of some form of payment. I am not suggesting that people should be paid to look after their parents. There is no doubt whatsoever that families are prepared to look after their parents but that does impose an economic burden on them. If, then, it is necessary to have some form of institutional treatment, surely it should be possible to design an institution to cater not for 200 or 300 patients, not even for 50 or 60 patients, but something on a smaller scale altogether.

I am reasonably familiar with the city of Dublin. If the children live on one side of the city and the parents live on the other, visiting can be an expensive matter, to say nothing of the the time involved. In the country, of course, visiting is much more difficult. We should have smaller units in which the requisite medical and nursing care can be given and to which families and neighbours of the old people can have free access. Sometimes a neighbour with whom one has grown up is more important to one than, perhaps, one's immediate family. It is very edifying to see old friends, themselves in poor circumstances, sacrificing time and money to visit a neighbour in the geriatric section of one of our hospitals. I recommend these two approaches to the Minister. He may have considered others.

The Minister did indicate that he is preparing a White Paper on mental illness. In the past 15 or 20 years, there has been an increasing awareness of the need to treat mental illness as an illness and to treat the mentally ill as just as much in need of care and help as the physically ill. There is at the moment large-scale investigation into mental handicap. The problem of the retarded child is a serious one. It is not getting attention. The best method of dealing with it is as a matter for expert examination and analysis.

I do not know if the Minister is satisfied with the ambulance services. From time to time there has been some complaint about these services. The crews and staffs, it is only fair to say, work in many cases under the greatest difficulty. Again, they get very little recognition. Their hours of duty and their rates of wages vary from one county to another. There is no common approach.

I should like to stress once more the urgent necessity of doing something about the cost of medicines. We have a shortage of hospitals and more problems will inevitably arise if the health services are not developed to the point at which they will become effective from the point of view of those who are prepared to make the necessary sacrifices to man these services. It is no good improving the services, if they are manned by cheap, underpaid labour. No matter what practical improvements are made, there will always be need for the same devoted attention and care now being given under very adverse conditions indeed by those employed in our health services. From these a contribution in excess of that normally given in other employments will always be required. These deal with the people who are ill, physically and mentally, with the aged, with the mentally handicapped and the mentally retarded, and all the time they work under continual strain. If we are going to have a charter for health services, written into that charter should be a special provision, as a prerequisite, governing proper conditions for those employed in these services. The anomalies, the inequalities and the injustices should be removed.

I appeal to the Minister to consider these points and the points made by other speakers. In his own confident fashion, he should indicate to the city and county managers that he has clear, strong and definite views, and that he is anxious than any injustices should be remedied without delay.

Mr. M.J. O'Higgins

I think it is a good thing to have this discussion here this evening on this White Paper but it seems to me that it is a discussion which should have taken place in this House at least five years ago. The Fianna Fáil Party, as a Government, and I do not pin the responsibility for this on the present Minister because he was not in that post at the time, had very concrete and comprehensive proposals regarding the health services put before them by the Fine Gael Party as far back as 1961. Since then, there have been five wasted years so far as the health services are concerned.

As a result of the proposals placed before the Dáil by this Party in 1961, there was established by the then Fianna Fáil Government a Select Committee on Health Services. I do not think it is necessary to deal in any detail with the subsequent history of that body but the point I want to make, and it is a valid point to make. is that if the Fianna Fáil Government at that time had considered the matter and adopted the same procedure as the present Minister for Health, we might have been enabled to have this discussion on the state of our health services five years ago. Instead of a Minister coming into the Dáil with a White Paper in 1966, that discussion could have taken place in 1961.

Even if it were thought desirable then to frame a White Paper in as vague a manner as many of the proposals in the present White Paper are framed, all that would have been done five years ago and whatever hurdles of a financial or other nature required to be overcome, they could have been dealt with and we might have had, even under a Fianna Fáil Government, some more adequate health scheme in operation now. Instead of that, we have the Minister coming in with this White Paper in 1966.

In the second paragraph of the introduction to this White Paper, the Minister makes it clear to all and sundry that there has been no particular thinking on his part, that even with the benefit of the advice he and his Party have received over the years from this Party, even with the results, such as they were, of the investigation of the Select Committee before them, the Government have not yet been able to make up their minds or come to any decision with regard to the detailed development of our health services.

The second paragraph in the Minister's introduction to the White Paper reads:

The Government would wish that the various proposals in the different parts of the White Paper should be the subject of wide public discussion before any final decisions are taken on their detailed development. The Minister for Health will be available to discuss them with appropriate representative bodies.

I want to express the hope at this stage that it is not going to be the design of the Government when the discussion in this House has been concluded to put this matter again on the shelf and to justify that action by that paragraph in the introduction to the White Paper. I hope it is not going to be the Minister's purpose to come back to this House even in a few months and tell the Dáil that he has been holding himself in readiness and available to discuss the contents of the White Paper with any representative bodies who wish to discuss it with him. It does seem to me, and I hope the Minister will disabuse me of this, that there is inherent in the very introductions to this White Paper the machinery whereby the Minister can justify placing the whole health question in abeyance again.

In the commencement of the third paragraph of the introduction, the Minister states this:

The changes proposed are complex and fairly costly.

And later on he refers to a considerable financial problem. He says:

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.

That is five years after many of the proposals which have now been apparently adopted by the Minister were shoved under the noses of the Fianna Fáil Party. Five years after we are told that they have not yet considered the legislation necessary to implement these proposals. We are told that the proposed changes are complex and that their complexity rules out any question of their implementation in the immediate future.

I do not think that is good enough. Again let me acquit the present Minister of any culpability in this matter because he was not in his present post at that time. I do not think it good enough in 1966, after long drawn out consideration, taking up practically the entire lifetime of the last Dáil that we should have that kind of statement in the White Paper now introduced by the Minister.

The White Paper then goes on to review, and review well, the growth of the health services, their development throughout the years and to indicate the services at present available. It is not until we come to page 30 that the White Paper comes down to practical matters. We in the Fine Gael Party have, for many years, urged on Fianna Fáil Ministers for Health not only the desirability, not merely the feasibility, but the urgency of tackling the question of our health services. We pointed out, and every Deputy who has spoken in this discussion has pointed out, the flaws they see and that their constituents have experienced in the operation of the health services as they now exist.

Five years ago and more, we were impressing on the Government that this was an urgent matter that required their immediate attention. That urgency has not diminished in the intervening years. It has been common for Deputies on these benches and on the Labour benches to point out that had this job been tackled even two or three years ago not to mention five years ago, the Minister responsible for endeavouring to set up changes in the health services, and to carry them through, would have found himself in a very much easier position, financially. This job could have been tackled and should have been tackled before the present economic and financial difficulties came upon us. Many of the proposals in this White Paper are worthwhile. Many of them are clearly taken from the advice tendered to the Government from these benches. But those proposals could have been in operation if that sense of urgency which we felt, and which we urged on the Government, had found a response in Government circles.

The Fine Gael Party proposals involved the extension of the idea of health insurance to the entire field of personal health. I think I am entitled to deal briefly with this matter because it has to do with the question of the financing of a health service. It is significant, but it is also disappointing, that, apart from the reference which I have read out in the second paragraph of the introductory statement and a reference later on, on page 59 of the White Paper, to the magnitude of the question of the finances, neither the Minister nor the Government give any indication in this White Paper as to how it is proposed to finance the proposals they are putting forward.

In their comprehensive health proposals, the Fine Gael Party were very detailed regarding the financial arrangements which they thought would be necessary. While we proposed a comprehensive national health service, we proposed one that would be based on the principles of social insurance and, basing a comprehensive scheme on the principles of social insurance, we proposed the provision of a full medical service, without charge, based on a doctor of choice and, so far as drugs and other requirements from chemists are concerned, based also on the chemist of choice. We said quite clearly in our policy statement that that should be financed by the ordinary recognised system of contributions payable as to one-third by the State and, in the case of employed persons, one-third by the employer and one-third by the employee. We recognise that, in endeavouring to bring in such a service covering not merely 29 or 30 per cent of the population as at present and as envisaged to be continued under the Minister's White Paper but 80 per cent or more of the population, provision had also to be made for the self-employed person, the farmer and other type of self-employed person. We proposed that there would be contributions from them and that this insurance basis would be compulsory. The calculations were made from the best sources of information we could get as to the probable cost of that scheme and it did not vary very greatly from the increased cost envisaged by the Minister in his White Paper—and that was a scheme which, as I say, was to be a comprehensive one. Our scheme was a scheme which would provide a very full medical service for up to 80 per cent of the people. It did entail, as the Minister's proposals entail, the disappearance of the dispensary system, but, in the Minister's White Paper, there is no indication given as to how his scheme is to be financed.

On pages 58 and 59 of the White Paper, the Minister deals with the question of cost. At paragraph 115, on page 58, he says that the estimated total cost for a full year of the specific improvements and extensions referred to in the preceding parts of the White Paper is £4,265,000. On the next page, he gives the breakdown of that figure and, in the middle of the page, there appears the sentence "It will be seen that there is here a financial issue of considerable magnitude".

I would ask the Minister to deal with this question in his reply as fully as possible: Is he considering or has he in mind, in connection with the financing of even the limited proposals dealt with in this White Paper, doing that on a basis of insurance contributions? The Minister has been silent about the matter; the Government have been silent about the matter. I know that when we originally made the proposal, and in one or two discussions here in the House, Fianna Fáil speakers endeavoured to knock the idea—but it was not the first time they swallowed the policies to which they had apparently been opposed.

I should like the Minister to deal quite frankly with the question of the system of finance to be adopted in connection with these proposals. Is the reason for his silence the fact that he does intend adopting another portion of the Fine Gael programme in relation to health and that he is considering the Fine Gael insurance principle as the basis for financing these proposals? It is certainly disappointing, in a White Paper as thoroughly and as fully written as is this one, to find in, roughly, the middle of it, the admission by the Minister that, so far as the classes of persons to be covered are concerned, so far as the percentage of the population to be covered is concerned, there will in fact be no extension whatever.

At the moment I think—the Minister will correct me if I am wrong— approximately 30 per cent of the people are covered by the existing health services. On page 35 of the White Paper, the Minister says:

As a wide extension of State operated or State organised general medical services has not been demonstrated to be necessary, the Government would regard it as undesirable and would not, therefore, propose that the limits to be fixed by the regulations mentioned in the preceding paragraph would be such as to include a high proportion of the population. Before the limits were decided upon, it would be proposed to survey all available statistical material on medical costs and, perhaps, to conduct some further sample statistical surveys of such costs, so that the limits could be related in a broad way to the present incidence of expenditure on general medical care.

The opening phrase of that paragraph 53 of the White Paper makes it clear, I think, that the Minister has had under examination in relation to the White Paper the Fine Gael proposals to which I have referred because the paragraph opens with the words:

The Government are aware of proposals recently made for the extension of the general practitioner service, with a choice of doctor, to the whole population or to the entire middle income group.

Then it goes on to knock the idea, on the ground that the Government are not satisfied that it is necessary and, not being satisfied, that they would regard it as undesirable to do that. But the salient point in all this is that the services are not going to be extended in any dramatic way so as to include a wider area, a greater field, taking in more people than are catered for at the moment.

The financial provisions are certainly not clear: they have not been dealt with in the White Paper and it may be that before the Minister's consideration of the subject is concluded, he will see the merits of the proposals in that regard which we have been urging. The Minister when in Opposition was a person who showed, certainly on one occasion—I have forgotten the particular quotation—very great concern for the overburdened ratepayers. I remember the picture he painted of the increase in rates and the necessity for economy at the top. I think his solution at the time was that the Government should set the example and amalgamate two ministerial posts, Justice and Defence. The Minister nods, so that my recollection is not too bad but the Minister's recollection will probably follow mine when I remind him what in fact happened when the Fianna Fáil Party got back to office was that, far from amalgamating those two offices, they gave the Minister for Justice a Parliamentary Secretary.

That is beside the point and the point I want to make for the Minister's consideration as a person who has demonstrated an interest in the question of rates, is to suggest that the financial proposals made by us do have the attraction of holding out a real prospect of a reduction in the rates on the score of health. In the White Paper, the Government have now come around to the view that it would be a good thing to allow a choice of doctor.

Mr. O'Malley

Before the Deputy leaves that, if I may interrupt him, I should be very interested to know what is the Fine Gael policy in regard to local authorities.

Mr. M.J. O'Higgins

Perhaps I shall get around to it.

Mr. O'Malley

The Deputy was on it. If he sticks to it now, I shall be fascinated.

Mr. M.J. O'Higgins

There is nothing that would fascinate me more than to see the Minister fascinated. The proposals of the Fine Gael policy in regard to finance were based on the insurance principle of one-third each way. Our estimate—and I think the Minister will not disagree with it—is that the cost of the Fine Gael proposals would be in the neighbourhood of £10 or £11 million a year, but that figure includes the £5 million-odd already being incurred in connection with these services. The cost of our proposals, as I have explained to the Minister, was to be met on the accepted social welfare basis of a contribution from the State, from the employed person and from the employer. We proposed that those who would be unable to make a contribution such as small farmers with a valuation, for example, of under £15 would not have to contribute anything and we provided that others, such as old age pensioners and unemployed persons, equally would not be required to pay a contribution.

As I had said when the Minister intervened, we calculated at that time that the net result of financing our proposals in that way would enable an attractive reduction to be made in the rates. The Minister will have to take this on faith for the moment: our calculation as to the amount by which the rates would be reduced by financing the scheme on an insurance basis was that the rates would be reduced overall by no less than £1 million a year. I think the Minister as a person interested in the question of rates reduction, at least would do well to look into that question.

Mr. O'Malley

The Fine Gael policy, for what it is, does not freeze the rates? In other words, as the services increase with the demand on them, local rates would increase year by year?

Mr. M.J. O'Higgins

No. I think the Minister does not get the point.

Mr. T.J. Fitzpatrick

(Cavan): He does not want to get it.

Mr. M.J. O'Higgins

If there are increased services when it is being done on the insurance principle, it is the people who are insured who will make the contribution. The State would have to make a contribution but the State contribution by and large, should work out at possibly a bit more than one-third of the whole because one-third was to be paid each way, employer, employee and the State. I concede this to the Minister: the amount to be paid by the State would obviously be slightly more than one-third because in the case where the small farmer in the category I have mentioned or the unemployed person or the old age pensioner or widow pensioner was not able to pay his or her own contribution, that contribution would have to be borne by the State.

Mr. O'Malley

But the health rate would go up every year.

Mr. M.J. O'Higgins

I do not think so.

Mr. O'Malley

If the services increase, they will cost more under the Deputy's suggestion.

Mr. M.J. O'Higgins

On my suggestion, at least, we would be starting £1,000,000 less.

Mr. O'Malley

The Deputy's illustrious brother, Deputy T.F. O'Higgins, said that his scheme will mean a reduction of ten per cent in the health rate, or, roughly, 2/- in the £. I have already met increases, for instance, in my own local authority, which would have meant 4/- in the £.

Mr. T.J. Fitzpatrick

(Cavan): Does the Minister say that he has frozen the health cost of local authorities this year?

Acting Chairman (Mr. Carter)

Deputy O'Higgins.

Mr. M.J. O'Higgins

Very well, Sir; may I put the question to the Minister? Is the Minister by his intervention making the claim that he has permanently frozen the local authority contribution as far as health is concerned?

Mr. O'Malley

Does the Deputy want me to answer that without the permission of the Chair?

Acting Chairman

The Deputy may not carry on this debate by question and answer. The Deputy may make his contribution.

Mr. M.J. O'Higgins

Well, now, Sir——

Acting Chairman

The Deputy may not crossexamine.

Mr. M.J. O'Higgins

It was the Minister who started the crossexamination.

Acting Chairman

Precisely. The Minister will also refrain from interrupting.

Mr. O'Malley

I have been so used to it myself in my time.

Acting Chairman

Deputy O'Higgins may be permitted to proceed.

Mr. M.J. O'Higgins

I am thankful to know that, anyhow. I was just about to say that I am not a person who argues with the Chair. I was quite prepared to accept the ruling of the Chair in the matter, although, indeed, I might say I made vigorous efforts but, unfortunately, unsuccessfully, to find a copy of a newspaper of the week before last because I wanted to deal with certain strictures passed by Deputy Carter on the Minister for Health with regard to the Longford Hospital. However, possibly before I finish we will get those. I do not know whether it was the Minister's object to take me off the line I was on. However, I propose going back.

Mr. O'Malley

Deputies always look after the interests of their constituents, irrespective of their political affiliation.

Mr. T.J. Fitzpatrick

(Cavan): By agreement, perhaps, with the Minister. That is for public consumption. Then you have other things at ministerial level.

Mr. O'Malley

Very wrong.

Mr. M.J. O'Higgins

If I am not permitted under the rules of order to ask the Minister questions, the Minister, surely, is not permitted under the rules of order to have asides directed at the Chair? Before the Minister perked up and started to interrupt, I was pointing out that one of the proposals which the Minister has now adopted in his White Paper, a proposal that, again, has been urged from these benches time and time again, is the provision of a choice of doctor. Under the Minister's scheme, there is to be a choice of doctor, as I understand the proposal, where possible, for persons in the lower-income group and, as a consequence of that, medicines, drugs and appliances would be supplied to the people entitled, in the lower-income group, through a chemist rather than through the dispensaries.

I do not think it is necessary to emphasise the fact that that proposal, as I say, is one which has been urged on the Government from these benches for a considerable time but it is clear that the class distinctions which exist as present, the division of the people into categories, lower-income group, middle-income group, and so on, is to be continued under the proposals outlined in the White Paper. The people are still to be divided into different groups, into different classes, depending on their means and, instead of arranging and organising the health services so that the bulk of the people will be covered by a comprehensive programme, we are still to continue under this White Paper with the kind of public charity approach. However, to the extent that the Minister has accepted the idea of free choice of doctor, obviously, we are not going to criticise his conversion in that regard.

Mr. O'Malley

About an hour ago, Deputy Lindsay said that it was overdue that politics should be taken out of health.

Mr. Coughlan

The Minister should practise what he preaches.

Mr. O'Malley

I am not saying it. It is what Deputy Lindsay says. I say that politics is the science of government.

Mr. M.J. O'Higgins

I do not know what provoked that outburst from the Minister. I remarked innocently that I did not propose to criticise the Minister in this regard. If I could make any approach less likely to drag health into politics, perhaps the Minister when replying would point it out to me?

Mr. O'Malley

I will do it straight away, if the Deputy will sit down and let me do it.

Mr. M.J. O'Higgins

Unfortunately, or fortunately, depending on the point of view——

Mr. O'Malley

The Deputy has to carry out his instructions to take until as near 10.30 as possible. Why does the Deputy not read the whole White Paper from beginning to end? This is nothing but quotations. We all read this thing.

Mr. T.J. Fitzpatrick

(Cavan): Did you?

Mr. O'Malley

Yes.

Mr. T.J. Fitzpatrick

(Cavan): Are you sure?

Mr. M.J. O'Higgins

I have so far given very few quotations from the White Paper, but if the Minister tempts me I might go into it a little more deeply.

Mr. O'Malley

I do not mind; I am not worried.

Acting Chairman

Deputy O'Higgins.

Mr. M.J. O'Higgins

In fact, I think it might have a salutary effect on the Minister were I to quote in extenso some of the Fine Gael proposals which were put before him and his Government so often and until now, with such little apparent effect.

In paragraph 42, page 31, of the White Paper, as I pointed out, the Minister gives his first concrete proposal and that is the one which, in the words of the White Paper, involves substituting for the dispensary service the service with, he says, the greatest practicable choice of doctor and the least practicable distinction between private patients and those availing themselves of the service. Again, even in that proposal, which is at least a reasonably concrete one, we have the air of vagueness incorporated.

I am glad that in the White Paper the Minister deals with the extension of both the district nursing service and home help services. It is made clear in the White Paper that the proposals regarding the extension are to be limited, in the case of home nursing, to the aged and the chronically sick. I assume that the reason for that is a financial one. It seems to me that one matter which requires attention is the greatest possible degree of domiciliary welfare service. The Minister does deal with a domiciliary welfare service and I hope he will agree with me when I say that I do not think there are any politics involved in this.

The views expressed by various speakers have demonstrated that there is a degree of unanimity on the matter. Again I should like to remind the Minister that this also was one of the matters with which the Fine Gael policy document dealt at considerable length when we emphasised that it was necessary to have such a service available for families so that sick members of the family would be adequately looked after in their own homes rather than in institutions. The Minister makes it clear that this is to be tackled to a large extent by the district nursing service. He has made it clear that no final decisions have been taken, that he wants this matter to be discussed and that he will hold himself in readiness to discuss it with representative bodies—for how long is not clear but I hope it will not be too long. I would therefore commend the thought to him for study that we have urged that a domiciliary welfare service be operated from a community welfare centre which would replace the dispensary as we know it and that that centre should be manned by trained social workers working in cooperation with the local clergy, the local doctor and local nurse and also with such officials as the home assistance officer, together with any voluntary charitable organisations in the district, of which, as other Deputies pointed out, there are many.

It is true to say that a home help service of that kind is necessary, particularly for old people so that not only can they stay at home but feel that they are encouraged to stay at home rather than go into institutions. In the White Paper, one of the matters dealt with is the tendency for increasing numbers of people to seek treatment as in-patients in hospitals rather than as out-patients. I am not able to put my finger on the precise page but my recollection of the White Paper is that the Minister sets out a number of reasons why that state of affairs has come about but is not by any means certain that the reasons advanced are conclusive. He goes on to point out that the average stay in hospital is being reduced. I suggest that one of the reasons why there has been an increase in the number of people staying as in-patients in hospitals rather than seeking either out-patients treatment or home treatment, is the framework of our health services at present.

One of the results of the present system, particularly in relation to the middle-income group, is that it was bound to lead to overcrowding in our hospitals. The position is that if a member of what is known as the middle-income group stays at home for treatment, and if he attends his family doctor, he must pay for each visit. Depending on the charity of the doctor, but assuming that in the ordinary case he gets a bill, he has to pay his bill for each visit to the doctor or by the doctor. I think I am also correct in saying that he will have to pay for the drugs and medicines he gets from the chemist.

I am not clear about the extent to which he has to pay, for example, for surgical appliances: I think the health authorities are entitled to render some assistance in that regard and it may well be that they are entitled to supply them free of charge. I know of some cases in which they are so entitled but if the person in the middle-income group chooses to stay out of hospital to be treated either at his home, or by visiting the doctor's home, then he has to pay for it. On the other hand, if he is admitted as a patient to a hospital, then his position is that he is liable only for a maximum charge of 10/- a day while in hospital. Any surgical appliances or equipment of that sort he requires are supplied free and there is no delay in supplying them.

The contention I would make to the Minister in this regard is that the present health services encourage people to go into hospital. Partly as a result of that, we have created overcrowding of hospitals and a shortage of hospital beds. At the same time as there is that overcrowding, I think the Minister will agree, there is no adequate ambulance service to convey patients either on a daily or weekly basis from their homes to hospitals to be treated as out-patients. The provision even on a small scale of a more adequate service of that sort— it need not necessarily be an ambulance service as we know it but some type of transport service specifically for the conveyance of patients from their homes to hospitals to be treated as out-patients on a weekly or daily basis— would make some contribution towards making our hospitals less crowded.

On the question of a child welfare service, which is also dealt with in the White Paper, the position at present is this. I am nearly afraid to quote from the White Paper.

Mr. O'Malley

It is all right. There are only 20 minutes to go.

Mr. M.J. O'Higgins

At present local authorities are only obliged to provide child welfare clinics in towns with a population of 3,000 or more. That is their obligation. It does not mean a local authority may not decide to provide a health clinic in a town with a lesser population. We proposed again in the policy document we produced in connection with the health services that there should be a child welfare clinic in all areas which would deal with children from birth to the age of 16. Judging from the White Paper, I do not think the Minister requires any urging regarding the necessity of a child welfare system based on clinics. I think he will appreciate that if we had sufficient clinics throughout the country, a remarkable amount of work could be done by them, notwithstanding the other services that already exist or would exist in proposed extensions.

Child welfare clinics of the sort I talk of and which we visualised in our policy document would deal, for example, with the immunisation and vaccination of children. They would be concerned with the prevention, discovery and diagnosis of disease. They would be concerned in a particular way with the question of advice and education for the children's parents. In relation, for example, to milk for mothers, it should be concerned with the distribution. In the White Paper the Minister has referred to the existing services but he does not propose any extension of them. A child welfare clinic of the sort visualised by us to be staffed properly should have attached to it probably the district nurse and a trained social worker, as well as the ordinary medical staff. I do not think the Minister has dealt with this aspect of the matter in his White Paper.

I should like to give the Minister the present of an idea well worth considering. It is on the question of child welfare education. We have on Radio Éireann at present a talk by a doctor once or twice a week of a general medical nature. I have heard it on a number of occasions because I think it comes before one of the news bulletins.

Mr. O'Malley

It comes after the racing results.

Mr. M.J. O'Higgins

I think it is interesting, instructive and well worthwhile. The suggestion I want to make to the Minister is that it could be extended both on radio and television into the child welfare education field. There might be frequent radio and television programmes for the assistance of mothers. In addition, the Minister's Department at present produce some pamphlets. I am not quite clear whether I am right in this or not. I know the Department of Agriculture are fairly prolific in the number of pamphlets they have.

Mr. O'Malley

That is the heifer scheme.

Mr. M.J. O'Higgins

My suggestion to the Minister is that, if it is not already done in his Department, there should be produced and distributed without charge pamphlets again dealing with general considerations of child welfare and child welfare education. On the establishment of child welfare clinics, it would be one of the functions of the social worker attached to those clinics to ensure that any publications of that sort would be distributed where they are required.

Mr. O'Malley

That is being done at present. Everything the Deputy mentioned in the last five minutes is being done.

Mr. M.J. O'Higgins

What about radio and television programmes? I do not think it is being done in this particular field.

Mr. O'Malley

The Deputy will appreciate that the pamphlets with the instructions are being issued, and there is a high percentage of these people that might not be watching at all. Women at a certain stage might not be very interested in watching these instructions.

Mr. M.J. O'Higgins

I am glad to know from the Minister that is being done. However, quite seriously, I would urge him to consider the idea of specific and specialised radio and television programmes.

Mr. O'Malley

That is a good suggestion and, of course, we shall have it looked into.

Mr. M.J. O'Higgins

I will not jibe at the Minister, if he accepts it.

Mr. O'Malley

There are a few more suggestions on the back page of the White Paper to keep the Deputy going for ten minutes. Whatever about milk for mothers, I have not had my tea yet.

Mr. T.J. Fitzpatrick

(Cavan): The Minister has plenty of Party members behind him to release him.

Mr. M.J. O'Higgins

If the Minister wants to have his tea, I would not like to stand in his way.

Mr. O'Malley

It will be breakfast at the rate the Deputy is going.

Mr. M.J. O'Higgins

That does not mean I would not fail to accept the Minister's invitation as set out in paragraph 2 of the Introduction to the White Paper.

Mr. O'Malley

The Deputy has read that twice already.

Acting Chairman

The Deputy must be allowed to make his speech.

Mr. O'Malley

Under Standing Orders surely he is not allowed to repeat himself?

Acting Chairman

The Deputy is making a speech on the Health Estimate.

Mr. T.J. Fitzpatrick

(Cavan): The Minister should obey the Chair.

Mr. Carter

The Chair will curb the Deputy when it thinks it is necessary to do so.

Mr. M.J. O'Higgins

The Minister has pointed out quite rightly that I have quoted this paragraph. I am not sure that at the time I quoted it, we had the same attendance of Fianna Fáil Deputies as we have now. However, let me relieve the Minister's anxiety: I do not propose to quote it again.

Mr. O'Malley

There is an interesting bit on the next page. Let the Deputy quote the second paragraph there.

Mr. M.J. O'Higgins

I am simply explaining to the Minister that while I would not like to keep him from his tea, I feel I would be failing in my duty if I did not respond to the Minister's invitation to ensure that this White Paper would be the subject of wide discussion.

Mr. O'Malley

It certainly is.

Mr. M.J. O'Higgins

There are one or two other matters which I should like to deal with and to have the Minister's view on, when he is replying. I referred earlier to the question of the domiciliary welfare service, to the question of a home help service which would, to my mind, be part of any comprehensive domiciliary welfare service. I want to make some serious suggestions to the Minister in regard to it. I hope the Minister will agree that if there were not merely a home help service for old people or the chronically ill, because that is envisaged in the White Paper, but a general home help service——

Mr. O'Malley

That is in the White Paper—"not only for the aged but"— even for the middle-income group.

Mr. M.J. O'Higgins

I am not disputing that. The point to which I want to direct the Minister's attention is the necessity for the organisation of a home help service to assist in dealing with the problem of children in care. I do not know—the Minister will supply the details if I have not got them— if there is a calculation made in the White Paper of the number of children in institutions and in industrial schools, on the one hand, and the number of children in care, on the other hand, that is, the number of children boarded-out and found foster homes. I understand that as between the two categories, there are roughly 5,500 children and that the breakdown of that figure is about 3,400 in industrial schools and a little over 2,000 boardedout.

With a properly functioning home help service, it would be far easier to have proper foster homes found for children rather than have them sent to institutions or industrial schools. The tendency to place children who need care in industrial schools rather than in foster homes would be lessened if there were available a skilled home help service, manned and staffed by trained personnel.

Mr. O'Malley

We shall examine that.

Mr. M.J. O'Higgins

I am very glad to hear that because again, if I may be serious despite the Minister's interruptions—and I hope that one was not intended facetiously because I should like the Minister to examine it—it would have a bearing, which would not be unimportant, on the question of the financing of the health services. I do not think this calculation is made by the Minister in the White Paper: the cost of maintaining children in institutions works out at something like £2 5s 0d a week per head as against something not much over £1 a week, the average paid for boarding them out to foster homes.

In relation to mentally handicapped children— I note that it is dealt with in only a cursory manner in the White Paper—one of the difficulties at the moment is the absence of any unified authority. Some of the functions in relation to mentally handicapped children have to be discharged by the Department of Education. The overall responsibility rests on the Minister for Health and, of course, the local authorities are concerned in the question. I would suggest to the Minister that he should consider, as a first step in dealing with the problem of mentally handicapped children, that there should be a single statutory authority charged with the responsibility of providing all necessary services. It would seem clear to me that if such a single, unified statutory authority is established, it must be under the general control of the Department of Health.

Progress reported; Committee to sit again.

The Dáil adjourned at 10.30 p.m. until 10.30 a.m. on Thursday, 31st March, 1966.