There is a certain unreality about the request of the Minister for Health to be paid another £1¼ million in respect of the health services. What is unreal about it is that the request has been made without any reference at all to the complete failure on the Government's part to honour the proposal which they made in a White Paper published more than two years ago. The proposal is contained in paragraph 116, page 59, of the White Paper on Health Services, published in January, 1966. It contained the following words:
The Government, having studied this issue, are satisfied that the local rates are not a form of taxation suitable for collecting additional money on this scale. They propose, therefore, that the cost of further extensions of the services should not be met in any proportion by the local rates.
Many of the services for which we have been asked in this Supplementary Estimate to pay, many of the services for which ratepayers are being called on to pay, are services which are set out on page 59 of the White Paper as being improvements and extensions in the health services.
The Government have failed completely to honour their proposal and this immediately brings into question the work of all undertakings or statements by the Government. It is most undesirable that in a matter affecting the health and wellbeing of our people the Government should have in such a disreputable manner welched to the extent that they have on the very specific undertakings so clearly and so frequently repeated.
This has brought about a situation in which ratepayers and taxpayers, 70 per cent of whom are denied all benefit under the health services unless they are so ill as to be in hospital, are being called on to pay the better part of £6 million—or will be so called on in the coming year—over and above the services which existed at the time the Government published their now in-famous White Paper. It has brought about that grossly unfair situation and other undesirable effects, one of which is that we now have some regions in the country up to 25 per cent of the dispensary doctors not being given permanent appointments because the Government are dithering on all health matters and are bringing about a situation in which some of the best medical brains and skills in the country are not looking to the public health services for employment because of the uncertainty that exists.
In Dublin Health Authority area, which caters for more than 25 per cent of our people, we now have a situation in which, out of a total complement of 83 dispensary doctors, 26 are temporary. Of that 26, 13 are occupants of posts which previously were permanent and the other 13 are occupants of posts which have been established since May, 1965, to meet the growing population and the increasing demands on our health services.
On 20th May, 1965, the Minister for Health in the present Government issued to all local authorities a circular letter saying that because it had been decided to introduce a choice of doctor into the general medical services, no further permanent appointments should be made. In that circular letter the Minister stated that it would be possible to arrive at decisions "within the next few months". There is a declaration of the Government that they would arrive at decisions in relation to the health services, in particular to the dispensary service and its staffing, within a few months of May, 1965, yet here we are three years later and the Government have not yet come to the decisions which three years ago they said they were about to make.
This is the kind of dithering incompetence and breach of undertakings which compelled the Minister to come once again to the Dáil to look for more money to bolster up health services which are as unfair as they are unsatisfactory and which are grinding slowly but surely to a halt. Were it not for the devotion to duty of the people who are administering the health services, were it not for their dedication and their contributions which go beyond the call of duty, our health services would collapse altogether.
In October, 1966, the present administration were obliged to recognise to some extent the harm which they were doing to the health services by the delays which were occurring. They therefore allowed health authorities to appoint dispensary doctors on a quasi-permanent basis without any rights to pension, without any rights to the other emoluments which go with permanent appointments. This is another indication of the injustices which are being built into the existing health services. There are several parts of the country where men are being appointed to posts without having the privilege of having such service as they may now give considered in future for pension purposes.
This is occurring even in areas where it is patently clear that dispensary doctors on a permanent basis will have to be employed in the future as they have been in the past, because if they are not so employed, there will be no medical attention available in those areas. The situation in urban areas is of course different from that in rural areas. We in Fine Gael have always accepted that. There is no justification for continuing any longer the inefficiency and injustices which are occurring under the present system because the Government have failed over a period of three years to give any attention to the obligation which lay upon them to honour undertakings which they solemnly, and presumably carefully, entered into.
There is no doubt that we are meeting a tremendous upsurge in the cost of providing drugs and medicines. This, as the Minister pointed out, is something which must be carefully watched but to some extent it could be beneficial if it results in keeping people out of institutions. That is the thing which we must aim at in this country, to reduce the institutional element in health costs, because that is the most costly end of it. It is an extraordinary thing that we in this country are the most hospitalised people in the world. We have more people per head of the population in hospitals than any other country in the world. The reason for that is primarily our failure to develop proper health services outside of hospitals.
I do not propose to enter into a policy matter but I feel it is important that we should reflect on that because that in itself is one of the most significant factors in the very heavy extra bill which we have for health services before us today. The increase represents some six per cent over what was estimated last year. This is due to a large extent to increased costs at all levels, as the Minister's introductory statement points out, but if these increased costs have to be borne by the national Exchequer, they have to be borne to an almost similar extent by local authorities. The contribution which the State is making to health costs at the moment is about 55 per cent of the total cost and the local authorities are left to find the other 45 per cent. However, this is not a true picture. It is important at this moment to realise what the true picture is.
When we quote these figures, we refer only to distinctly medical services and we are not taking into consideration the tremendous contribution which several local authorities are making to new medical services which to date do not qualify for a grant from the Exchequer. Dublin Health Authority raised this matter recently with the Minister for Health, who, I think, was not unsympathetic to the argument that if health authorities are now paying, as they are, considerable amounts of money to provide a meals-on-wheels service for old folk, to provide domiciliary nursing services and other schemes to keep people out of institutions, they ought to receive at least half of the cost of those schemes from the national Exchequer. I do not think it is sufficient answer to say to health authorities that this is not a matter for the Minister for Health, that it is a matter for the Department of Social Welfare. These things should not at all be considered as in the nature of public assistance.
The Minister knows well that the only reason these schemes are being financed out of public assistance at the moment is that if they were not financed from that source, there is no other source available within existing legislation to finance these schemes. We thank God that these schemes are in operation and we thank also the wonderful lay and religious people who are making these schemes possible, but having expressed that thanks, we must say that if they were not in operation, the health bill would be many times greater than it is and the Minister's Supplementary Estimate today would be for over £2 million and not the £1¼ million he is seeking. I would therefore like to hear from the Minister whether he has been able to make any progress with his colleague, the Minister for Finance, or his colleagues in the Government, with a view to having these quite clearly medical services paid for by the State.
I think it is also safe to mention in relation to the increased cost of drugs and medicines that while it reflects undoubtedly new practices in modern medicines and drug therapy, it also reflects a considerable amount of questionable commercial activity by the drug manufacturers who carry out the most intensive advertising campaigns involving the giving of free samples to members of the medical profession and the pushing of drugs and medicines and preparations, some of which are of highly questionable quality. I know that at the moment there is a committee considering the establishment of some formulary which would be accepted so as to avoid the unnecessary prescribing of highly-priced modern preparations. I hope that the Minister will be able to assure us that some really worthwhile progress will be made in this field in the very near future so as to remove from this very important part of medical skills this undesirable commercial pressure.
We do not begrudge the addition of £200,000 in the Estimate in respect of remuneration because we appreciate that a considerable amount of this is due to shorter working hours, particularly for nurses. Indeed we must be concerned with the fact that many people in our hospital service who are entitled to shorter hours are obliged, because of inadequate staff, to work overtime, sometimes with danger to their own health and welfare and indeed the welfare of patients. We hope the Minister will take all steps necessary to ensure that shorter working hours which have been given to various grades will in fact be possible of achievement. This can only be done if we increase our nursing complement.
In that regard I would ask the Minister seriously to consider providing for married nurses who want to come back into the service pay scales equivalent to what they would get if they had not married at all. We are entering into an age in which we must recognise the principle of equal pay for equal work, in which men and women must be paid equally, and in which married and unmarried women must be equally paid. It is invidious to push a system under which a highly skilled and experienced nurse with several qualifications is obliged to work at the rate paid to a young nurse just qualified merely because she is married.
This, as the Minister knows, in the Dublin region has led to a situation in which some of the Dublin hospitals, particularly local authority hospitals which are curtailed in what they can pay by ministerial direction, are unable to get a sufficient complement of nurses. One hospital, Cherry Orchard, has a whole unit consisting of 28 beds closed down for no reason other than lack of nursing staff. This could lead to a very serious situation. Nobody would be more embarrassed by that matter, if any crisis did arise, than the Minister. I would urge on him to relax the rules. They have been relaxed in the educational sphere where it became necessary to provide teachers. The important consideration must be the provision of adequately trained staff with proper wages. I would, therefore, urge the Minister to see to it that married nurses who want to come back into the service will be paid at the appropriate rate. We appreciate that the Minister is concerned to maintain fair rates and reasonable opportunities for unmarried nurses and that they cannot be lightly overlooked but at the same time the needs of our hospitals and the attention of the sick people must take precedence over any other consideration.
There are many other matters on which I could dwell but this is a Supplementary Estimate and I think the need for this Estimate has been out-lined by me at the outset. It is primarily the Government's duty to provide proper health services. I earnestly hope we will not have much longer to wait. We are not comforted by the assurance the Minister gave earlier this year to the Dublin Health Authority when he said he was carrying out a reappraisal of the health services. We would have thought that that should have been done long ago. Goodness knows we had a select committee sitting on the health services in this House for six years and it is almost three years now since the Government took the decision to amend the present health services. It is not good enough to receive an assurance at the end of those nine years that there is now to be a reappraisal of the health services. Surely that should have been done long ago. Let us hope that this is the last year that Dáil Éireann will be asked to make good the default of the Government which has led to this continuing burden on taxpayers and ratepayers, most of whom are as I say deprived of all benefit under the existing health services.
