If the Government had honoured the undertaking which was given, and often repeated, in 1966, to keep——
Committee on Finance. - Vote 48: Health (Resumed).
Debate resumed on the following motion: "That the Estimate be referred back for reconsideration."— (Deputy Ryan.)
On a point of order. May I say that I appreciate that Deputy Ryan was interrupted twice while he was speaking but nevertheless I would point out that Deputy Ryan is now making the same speech for the third time.
Repetition is not in order but the Chair is not aware that Deputy Ryan made the statement before.
I have spoken about 20 words and I find it difficult, therefore, to understand how the Minister can assume that I am about to repeat what I have said already. In fact, the Minister is quite wrong. However, I insist on speaking in this debate about the failure of the Government to honour an undertaking in the past three years. I am entitled to do so—particularly when I can demonstrate the consequences of that failure by the Government.
That undertaking was never given.
I pointed out that it had the effect, in the current year, of keeping the rates 8/- to 12/- in the £ higher than they ought to be. Before I was so improperly interrupted by the Minister, I was about to say that, instead of limiting its contribution to rates or to certain health charges to 55 per cent, the State should now be paying not less than 68 per cent of the charges for which the State accepts responsibility under existing law and under the undertakings which we maintain were given originally in the White Paper and which were repeated again and again and again.
We will quote chapter and verse to show that the undertaking was to peg the charges to what they were in 1965-66. But, even if the undertaking was never given, the justice of the case requires that they should not have risen beyond the figure at which they were in 1965-66, at a time when the Government accepted that it was wrong, unjust and inefficient to use rates as a means of financing the health services. Having accepted that, in principle, and having given an undertaking within a year of the publication of the paper to propose a new system for the financing of the health services, the Government gave an undertaking which, we maintain, meant exactly what we said it was intended to mean. Throughout the Presidential Election, Fianna Fáil speakers often repeated it to me. The undertaking was to ask the rates to pay not one penny beyond what was paid in 1965-66.
Even setting aside the broken promises, which are a source of embarrassment to the Minister, we base our argument on the justice of the case in present circumstances. We accept that the removal of all health charges, or some of them, from the rates to the National Exchequer is simply transferring the burden — but it is transferring it from one seventh of the population, many of whom find it impossible to bear, to all of the population, most of whom would find it a lot easier to pay than many of those who are now called upon to pay it.
I am glad the Minister, in his opening statement, dealt with the question of the substantial increases in the amount now spent, and spent in recent years, on drugs and medicines. The Minister has, I think, very properly taken the attitude, which we in Fine Gael take, namely, that it is desirable to spend more money on drugs if, as a consequence of prescribing and using some modern drugs, a person's health is restored more quickly. After all, a person working and producing will produce wealth. A person not working is a burden to himself and to the whole community, even if he never went into a hospital. If, in addition to not working and to being a burden on the community, he has to go into hospital, then there is a tremendous loss. An expenditure of £3 on one prescription is far better than an expenditure of £3 or £5 per day on the maintenance of a person in hospital over a period of several weeks.
It is important before becoming excessively excited about the cost of modern drugs to realise that even in our public health service, such as it is, nearly 70 per cent of the money is spent on looking after people in hospitals, whether public hospitals or voluntary. Only about 9 or 10 per cent of the total cost is spent on what are called general medical services. These are in the provision of medical services for people outside of homes and institutions. In the urban areas in the Dublin region this figure falls down as low as 5 per cent. When within the figure for general medical services you have the remuneration for dispensary doctors, for nurses and for the maintenance of clinics and so on it will be seen that the actual cost of drugs, even with the multiplication of the overall cost in recent years, is only a minute fraction of the total cost of the health services. We believe it is something which augurs well for reduction in the greatest cost of health services and that is the cost of costly institutions.
We in Fine Gael would like to press the Minister to extend without further delay the school medical services to provide for all children in post-primary schools. As a result of an increasing number of children proceeding to secondary schools we are depriving many children, who hitherto enjoyed free medical services up to 14 years of age, of two years or more of supervision and assistance in relation to health which they previously enjoyed. We should also like to see an end to the requirement that a defect in a child must be found in the course of a school medical examination in order to entitle the child or its parents to assistance from the public authorities. It should be a matter of no consequence where the defect in a child is ascertained.
Unfortunately, it is in many cases a matter of pure luck whether the hasty screening which is conducted in school medical services will disclose an ailment in a child at all and to say that this unfortunately haphazard and inefficient system is the determining factor in whether or not parents are to receive assistance towards meeting the cost of health services for children is to impose what is known to be an inefficient system of determining faults. In many cases it leads to extreme hardship where the parents are prepared to make immense sacrifices for the sake of their children. In other cases, even with immense sacrifices, the cost of providing necessary medical care is beyond the capacity of the parents to bear. I hope that the day will soon arrive when there will not be that qualification as a condition precedent to receiving full assistance from the State and public authorities for the improvement of our children's health. If we can build up healthy adults and have healthy children going into adulthood we can substantially reduce our overall medical costs in future years.
The Minister referred in his opening statement to the report on the future development of hospitals. I should like to make a few points in this connection. We fear that there is a danger that the recommendations that have been made will be implemented without sufficient regard being paid to local conditions, difficulties and habits. I have in mind in particular the problem facing the people of Donegal where it is proposed that the new hospital serving the south west Donegal area will be situated in Sligo. This, because of the nature and extent of that region, will impose journeys of 100 miles and more on many sick people in that area who seek necessary hospitalisation. We feel there are special cases like that, no doubt, in other parts of the country which require a reassessment of many of the recommendations in the report. I think we can say this without in any way qualifying the overall recommendation that there must be a rearrangement of our hospitals so that full value can flow to the community from all the capital expenditure, all the modern equipment and all the specialists available and on which we are more frequently than ever before depending.
The Minister took umbrage recently when I queried the degree of freedom he was going to allow in future to voluntary hospitals. I see again that, in reply to Deputy Dillon last week, he expressed his distaste for what I had said in the previous week. I am not at all convinced that the Minister is as careful not to limit the authority and responsibility of the managers and owners of voluntary hospitals as he ought to be. It is not sufficient to say to a person, when you are strangling him to death or to the point of causing him discomfort, that you are not doing it at all. You do not convince a man that you are not going to kill him simply by uttering at the time of drawing the gun on him or driving the knife into his back that you are not really going to kill him. The fact is there are at work in this country people who are most anxious to take away from voluntary bodies, including dedicated religious orders, much of the responsibility which is theirs. If it is theirs, it is due in the main to the sacrifices that have been made by such people down through the centuries. In both the lay world and the religious world there are many who have given immensely of their own personal effort and of their own wealth to build up institutions which could never be replaced by any scheme of State assistance.
Therefore, once again I urge the Minister to ensure that whatever new arrangements will be made freedom will be given to the owners and managers of hospitals to a degree which will enable them to apply their own particular skills and services without unnecessary restrictions. It would be wholly undesirable if many voluntary hospitals, which because of the freedom they have at present are able to draw upon the charity of the community, were to find themselves mere creatures of the State and because of that could no longer call upon or receive support and encouragement which they now get from many voluntary sources. That is the real danger. There is also the danger that voluntary hospitals, which at the moment are able to develop certain skills and services because of the freedom they have, would find themselves inhibited in future to the extent which now applies to many public authority hospitals which have been prevented, time and again, by the dead hand of the Department of Health from expanding or becoming more efficient or introducing new services.
We know that the justification for giving the Department of Health an overall control is to prevent wastage and duplication, to superintend costs and make sure that no local authority or voluntary hospital goes berserk in the expenditure of public money on hospital services. I believe there are many cases in which the delay imposed by the Department of Health on many worthwhile schemes has resulted in greater loss to the community than would have been the case had the original expenditure gone ahead, unchecked and unprocessed by the Department of Health. I suspect there are many members of local authorities, health authorities and hospital authorities in this House who could in their own experience list cases in which costs have been multiplied because of gross delay on the part of the Department of Health. I will not weary the House with a list for the Dublin region. They are legion. They are most frustrating and they have resulted in substantial loss to the community, the State and the local authority.
Why not bore the House? Why not give the list?
If the Minister wants me to go on longer than he was prepared to suffer earlier on, I can do that.
I never object to the length of time a Deputy speaks.
So long as he does not repeat himself. There is a danger that we will accept that the largest unit is the most efficient, but that is not necessarily so. In relation to human service and personal service which, in the main, are medical and health services, the smallest unit is often more practical and more efficient in both cost and the service it gives to individuals. Human services are best on a small scale. Material services are probably better on a larger scale, but we ought to ensure that the foundation of our health services is in future human rather than material. We would hope that in any reorganisation which the Minister may have in relation to hospitals or administrative areas he will not be so passionate in his desire for large size that he will overlook the basic truth that human service ought to be on a small scale. I think that the health authority in the Dublin area is already too big. It is catering for about three-quarters of a million and it is trying to provide not only hospital services but human and personal services as well. In other countries research has shown that the largest area most appropriate for good health services will never exceed 300,000 people and that means that the Dublin region, if there is validity in these figures, is more than twice the size it ought to be. I know that in relation to hospital services there has been a rather arbitrary, but I think valid, introduction of a division based upon the River Liffey and that new services will be developed to the north of the river without regard to the south of the river and vice versa. The Minister should be extremely careful in ensuring that he does not create large monsters because they can never be the answer to the health needs of our people.
Might I urge upon the Minister that he would give his approval as soon as possible to the provision of adequate residential accommodation for nurses in St. Kevin's Hospital? This hospital is the largest in the country. In recent years it has very successfully launched a nurses' training school which, in the short period of its existence, has created a very good reputation for itself and has produced some really excellent nurses. Unfortunately, however, within the existing St. Kevin's institution there is nothing like the residential accommodation necessary.
In recent years there were attempts, out of the resources of the health authority, to make arrangements to provide some residential accommodation, but this accommodation is only a small fraction of what is required and it is undesirable to waste time and money on conveying trainee nurses from St. Kevin's either to St. Mary's north of the river or to the proposed new temporary accommodation in Cork Street. This is expenditure which is compellingly and urgently required. I would hope the Minister would see his way to giving his approval to this without undue delay.
There is also a growing shortage of trained nurses. The Department of Health and An Bord Altranais have been reluctant for too long to ensure that married nurses are adequately remunerated. In the Dublin region there are hospitals in which beds are vacant not because the number of people seeking admission has fallen but because the health authority has not got available the nurses necessary to staff the wards. This occurs even in catchment areas in which there are numbers of married nurses available, but these will not return to public hospital service because the rates of remuneration are not sufficient to entice them away from their homes. If married nurses returned to public service they would find themselves, after payment of income tax and domestic help, receiving as little as £4 or £5 a week for 50, or more, hours' work, most of which would be during the night. It is, therefore, incumbent upon the Minister to ensure that the disadvantages from which married nurses suffer are removed. I do not think it would mean any depreciation in the conditions of service or reduction in the wage rates of unmarried nurses. It is quite ridiculous, and it means a loss to our community, to operate a system under which experienced, well-qualified nurses receive little more than the basic rate paid to a newly-trained nurse simply because they happen to be married. The fact that they are married probably gives them a qualification for nursing which unmarried nurses would not have. We ought, therefore, to encourage the employment of married nurses. For years, the Minister for Education was extremely slow in allowing married women teachers to return to the public services, but he was ultimately obliged to do so because of the shortage of teachers. Before there is any further loss of health or hospital services we should provide adequate remuneration to encourage married nurses to come back into the nursing service.
We would also urge the Minister to consider a scheme to allow for the employment of State enrolled nurses. This is a category of nurses which could be particularly helpful in urban areas. There are several such girls available and we would urge the Minister to allow health authorities to employ State enrolled nurses at adequate rates of remuneration.
I mentioned earlier the need to extend the school medical services into the post-primary area. In that connection might I also urge upon the Minister that he should allow an extension of full dental care for children into the post-primary area? As a result of recent developments there are many children now denied what is admittedly utterly inadequate dental care simply because they have gone into secondary schools but, bad and all as the public dental system may be, it would be better to extend it to children in post-primary schools rather than exclude them from benefit altogether.
There are a couple of points the Minister made upon which I should like to comment. The payments made in respect of infectious diseases are grossly inadequate. As I pointed out earlier, health authorities throughout the country are obliged to supplement that which the Minister allows to be given under this head because the allowance is totally inadequate. I would urge that, although there was an increase from August, 1967, the time has come to give a further increase in these allowances for infectious diseases and for disabled persons.
It is interesting to note that in the Cork region, per head of the population, there are twice as many people receiving disabled persons' allowances than are receiving them in the Dublin region, and both those regions have a higher rate for such people than have other areas. This indicates the unequal way in which our health services are being applied. The fact that so many of these people are being assisted in this way in Cork is, I understand, due to the fact that in the Cork area there are many excellent voluntary organisations providing care for disabled people. Where there are such organisations operating, they find disabled people who are entitled to benefits to which they did not know they were entitled, and the result is that calls are made upon the health authority.
In the Dublin region, notwithstanding immense improvements and increased activity on the part of voluntary bodies and the health authority itself, we still assist only half as many of these people per head of the population as are assisted in the Cork region. This supports what I argued earlier, that we have in our midst much more human suffering than we yet know. High as the health costs are, if we were doing what we should be doing, helping everyone who needs it, the cost would be very much higher.
I promised earlier to find the reference in the Minister's speech to what he was going to do about coming to the relief of the ratepayers. I should like to say, therefore, that it is contained in page 7 of his circulated statement. We had words before like "urgent reappraisal" and "careful examination" and so forth, to indicate the way in which the Government were doing nothing about coming to the assistance of the ratepayers. The lovely phrase the Minister used last night to indicate that he was doing nothing, was that the arrangement to be made for financing health expenditure is at present being urgently considered. That is the latest description for doing nothing of any assistance to the unfortunate ratepayers.
The Minister tells us that, in relation to the forthcoming financial year, the only undertaking he can give us is that the share being met by the State will not be reduced next year. May I say to the Minister with all the generosity of my heart that I thank him for nothing? I pointed out earlier that the State contribution towards the overall expenses of the health authorities amounts to 46 per cent only. Many of those expenses arise simply because the State welfare payments are grossly insufficient to maintain body and soul together. Although that is so, the State is paying only 46 per cent in this respect.
The Minister mentioned that great strides have been made in recent times in detecting potential mental handicap in children. This certainly is an encouraging trend. He also mentioned that the treatment for this ailment is a special diet which can be quite expensive and that he has asked the health authorities to look sympathetically at all requests for assistance towards the provision of this diet. The Minister said that, notwithstanding the fact that 82 per cent of all the children in the country were screened for this condition, only 37 cases have yet been detected. That is a very high number when you consider the way in which those 37 individuals have been saved the misery which would be theirs if they had developed as mentally handicapped people, and the misery which would be the lot of their parents and relations and friends if they had developed as mentally handicapped, and the high cost to the community if for the life span of any one of them, they had to be maintained by the community.
I wonder would the Minister be good enough when he is replying to indicate whether the State will give if not all at least a substantial share of the cost which the health authorities will have to meet if they are to bear all or part of the expense of the special diet to be provided for such children. Here, again, is an area in which by the application of modern techniques considerable expenditure can be avoided. It is an activity which should be encouraged and, in order to encourage it, the State should bear at least the same proportion of the cost as it is willing to bear for other health services at the moment.
I thought we were giving nothing. The Deputy said that a moment ago.
The Minister should read my speech if he cannot absorb it now. As I understand the present position, unless the Minister is prepared specifically by legislative proposals to assist the health authorities in the cost of providing these special diets, the health authorities will have to bear the full cost out of the rates, because this does not directly appear to be the kind of health activity which would carry the statutory subvention which the central Government are at present obliged to give. Therefore, it behoves the Minister to ensure that the health authorities are assisted in the provision of special diets for these children.
We join with the Minister in urging parents to have their children immunised against diphtheria and to have them vaccinated against polio. In Dublin in recent times, unfortunately, we had a number of cases of polio. The sad thing is that each one of those cases arose in people who were not vaccinated. We did not have any instance of the disease in 1967. There were two reported in 1968. Although we are only in the third month of 1969, seven cases have been reported this year. These are all cases in which the children involved were not vaccinated. In one case I know medical advice was against vaccination. No one can fault parents who receive medical advice not to vaccinate or immunise their children. It is a very simple procedure. It behoves all parents to provide the protection which their children are entitled to and which the State is prepared to give free against diphtheria and polio.
In relation to diphtheria the only cases of deaths in recent times arose where there had not been immunisation. These are avoidable risks. These are avoidable deaths. These are avoidable illnesses. It is extremely urgent that we should ensure that all parents become aware of the immense dangers to which they expose their children unnecessarily, if they do not have them immunised and vaccinated. I am very much against compulsion of any kind in relation to medical or personal services. I think I am on record in that regard. I am as much against compulsory immunisation or vaccination as I am against compulsory fluoridation but as one can properly take a stand against invasion of personal liberty, so one must with equal emphasis take a stand in favour of exhorting people to do the right thing. Doing the right thing by conviction is far better than doing it because it is compulsorily imposed upon you.
Is it correct to say that three lumps of impregnated sugar taken at intervals are enough to immunise a child against polio?
Yes. The sad thing is that quite an encouraging number of children are brought along for the first lump of sugar, but then the graph declines. I have no doubt it is often due to pressing domestic difficulties which cause parents to postpone going back for the second or third dose. It is the old case of the medicine being helped to go down with a spoonful of sugar. The children like it. It is such a small thing, it almost seems unimportant. That, perhaps, is part of the tragedy. If it required a visit to a doctor's surgery and the application of all kinds of fearsome looking instruments people might be inclined to treat it more seriously. It is such a simple procedure that it is a terrible tragedy that so many people do not go through with the full course.
May I prompt the Deputy to say that all that has to be done is to bring your child to St. Ultan's where they will give him a lump and tell him to come back and get another one and then another one? That is all that has to be done.
It is made easier even than that. In the Dublin region and, I am sure, in other areas, from time to time there are polio vaccination clinics or services provided in local halls, dispensaries, local health centres, parish halls and parents in the neighbourhood are circularised so that they may come at times convenient to them. Notwithstanding all that, there is still a significant proportion of the population who fail to take the necessary steps. Even if a person misses out at any of these communally organised vaccination sessions it is open to parents to bring a child to any of the children's hospitals at any time and get the service free, gratis and for nothing no matter from what section of the community they may be drawn. Whether they wear fur coats or sackcloth the service is available on the same terms.
The Minister has told us that he proposes taking powers which may be necessary to deal with the problem of drug abuse. We are glad he is doing so and would urge upon him not to delay action in this vital field. It is terribly important that we would save our country from the horrors of drug abuse which have visited other communities. It is an abuse which, unfortunately, is beginning to creep into our midst, probably due to influences from abroad. I note, however, the Minister mentions making the unauthorised possession of certain drugs an offence. We would hope that he would take a more positive step towards the solution of the problem of drug abuse than making the possession of drugs an offence. We have no wish at all that he would be soft or easy on this problem. We believe it calls for vigorous and courageous action. The application of punishment after doing something which the community regards as being wrong will not prevent young people who are the particular victims of drug abuse from trying it in the first instance. We think, therefore, that this is a field in which education could be far more effective than punishment and any schemes of education or advice or training which can be applied ought to be applied with maximum speed.
One can see a danger sometimes in an education programme that by the mere process of education you can sometimes stimulate interest and curiosity which might not otherwise exist. It is perhaps not desirable to enlarge this problem or to create an unnecessary scare because to do so only creates an unhealthy interest in something where such interest might not otherwise exist. It is a difficult problem. We do not make light of the Minister's difficulties in this regard. We wish him well in any steps he may take and undertake not to make more difficult the path which we accept is an extremely difficult one.
The care of the aged is something that we are glad to see is having the increased interest of the Minister for Health. We think this is a reflection of the anxiety of our community to look after the elderly in our midst. We are fortunate to be living in a community which has become more and more concerned about less fortunate citizens. I do not know whether it is due to the mass medium, television, that people are becoming aware of the problem. We must thank all the mass media for the increased interest which is developing in the care of aged people. This is a humanitarian obligation but it is also an economically desirable step to care for the aged because by caring properly for them you maintain them in good health and happy to the end of their days, living in the community where they have as much to give as they get. That is something we want to get our people to realise, that our community can gain as much from the company, assistance and advice of healthy old people as they are called upon to give. Some day, if God spares us all, we will find ourselves in the same class. We would hope when that day arrives for us that more would be done by our society than has hitherto been done. The provision of additional diagnostic centres for old people is one of the most important steps which can be taken in this regard.
The provision of additional psychiatric centres in general hospitals is something which can be of immense benefit not only in the care of the aged but, indeed, in the care of other sick people also. This is something which the General Hospitals Report emphasises and which has been emphasised elsewhere, that we must have in all our general hospitals the psychiatric clinic and psychiatric ward.
We must break down with all the speed that we can command this dreadful barrier which still exists which distinguishes between physical illness and mental illness, treating physical illness as something not to be ashamed of and mental illness as something to be locked away, something to be afraid of, something which is demeaning. There is, perhaps, no more positive way of doing this than by merging our psychiatric service into our general medical services and ensuring that all general hospitals contribute their share in the care of psychiatrically sick people as they do in looking after physically sick people. We must welcome the significant drop in the number of in-patients in mental hospitals.
I hope the Deputy will not pass from geriatrics without mentioning visitation and home-nursing.
I would be all too willing to proceed on the lines very properly indicated by Deputy Dillon but I fear the Minister is extremely sensitive to the possibility of my repeating anything to which I have already made reference in the course of my modest contribution.
Not at all. The objection is only to repetition of allegations.
Of statements with which the Minister disagrees.
Statements which are not accurate. There is no objection whatever to the Deputy dealing with the subject mentioned by Deputy Dillon.
As I have been most careful not to indulge in any repetition, on the point where the Minister either agrees or disagrees, I would not wish to depart from this high standard that I have endeavoured to observe.
We welcome the significant drop in the number of persons who are retained more or less permanently in mental hospitals. We must not be alarmed but must rejoice in the even greater increase in the number of patients attending the out-patient clinics of mental hospitals. This is the kind of development which could mean substantial improvement in the mental health condition of our people.
We are not going to have any worthwhile improvement in this regard, especially in relation to the in-patients institutions, until another generation passes away because we allowed to grow up about us here a system under which many people went into colossal hospital institutions at a relatively early age, where they were taken care of, put into a state of suspension, relieved of those pressures which afflict us mortals who are lucky enough to be in the outside world and who live to a hoary old age. It is not unnatural to find in mental institutions people who have been there 20, 30 and even 40 years. We should not allow this to happen in our age or in future. It is clear from the study of geriatrics that a great deal of this is avoidable. We must take steps to ensure that this dreadful thing does not happen again.
In his lengthy statement the Minister contributed no more than three and a half lines to the most questionable activity in medicine in recent times— the fluoridation of water supplies. I am glad to say he has paid more attention to what many of us advocated— fluoride mouth rinsing which could be a helpful way to combat dental caries. Apparently whether people elect to have fluoridation or not, this is to be available only to those who are fortunate enough to have piped water. I think it will be found in time to come that we have only attempted to postpone dental caries from childhood to adulthood and that it will be left to another generation to deal with that costly problem.
In relation to general hospital services the Minister mentions that there is a steady growing volume of demand for hospital care. Is the Minister quite right and if so has he examined why? We in Fine Gael believe very strongly that one of the biggest reasons for pressure for hospitalisation arises out of the gross inadequacy of medical care at home. We have a situation in which we devote five per cent of our total medical costs to the provision of medical care for only 30 per cent of the population in their own homes. If we increased that to 15 per cent we would provide medical care in their own homes for 90 per cent of the population and there would be a complete change in the curve of the demand graph for care in hospitals.
I do not intend to deal in detail with the problems of the region with which I am most familiar because I believe that in a debate of this kind we should relate our remarks to national problems because we get opportunities through our own local authorities to press our individual problems. Accordingly, I should like to refer to the suggestion that a new general hospital should be established at Blanchardstown. The Minister for Health appears to hold the view that in addition to providing an immediate 120 beds at Blanchardstown for general hospital cases the balance of the buildings in the existing Blanchardstown compound could be used for a further extension of the general hospital. The consultants and managers of the voluntary hospitals concerned and the medical advisers to the Dublin Health Authority, and the members of the Health Authority itself are of the opinion that the remainder of the buildings at Blanchardstown, excluding those containing the 120 beds, which it is now proposed to give to the Minister, are unsuitable to be brought into general hospital arrangement. They are far too removed from the general hospital.
While the Dublin Health Authority and the voluntary hospitals are only too willing to line up with the idea of the creation of a new hospital in Blanchardstown, with equal determination we say that the balance of the buildings at Blanchardstown are wholly unsuitable for incorporation in a general hospital. If the Department of Health feel they can get in the thin edge of this undesirable wedge the Minister and his advisers may as well know that the main concern of the people, who are only too willing to help in relation to the development of a hospital at Blanchardstown and to the giving over of a number of beds there to the Minister, is in the future of a general hospital in Blanchardstown.
I am not saying anything about the compelling urgency to maintain at Blanchardstown or anywhere else a sufficient number of beds for TB patients or to provide there or elsewhere the specialised care for diseased chest cases which are at present looked after at Blanchardstown. Even if the Minister were to provide accommodation elsewhere for those cases—and there is no indication at the moment he would be willing to do so—the argument against Blanchardstown would still stand—that it is not suitable to be used in the future for the kind of development which was seen in the Fitzgerald Hospital Report. If Blanchardstown is to be used—and there are good reasons why it should be used—it can only be used if there is a substantial amount of capital moneys expended on the erection of a new hospital and to consider it in any other light is to waste time.
We cannot test health services on quantity alone. We can argue about the methods of financing hospital and health services and we can say that cost must be a limiting factor but we must never lose sight of the fact that there are many statistics which can never be ascertained. The people may have impaired eyesight and be without spectacles because they find the cost beyond them. That is a statistic which is never recorded. Such a person's impairment will never be known. That is also the position in regard to who has defective hearing. His hearing will always be defective because he cannot bear the cost of purchasing a hearing aid. That will never be recorded either. There are many people suffering from gynaecological diseases, there are men suffering from hernia and there are people suffering from a variety of maladies which are never assessed by the statisticians or medical experts and will never be recorded. There are sufferers from many diseases which are not fatal in themselves but which can inflict pain and suffering. Such diseases may not involve the incurring of hospital expenses and not appear in statistics.
There is an obligation on any Christian community to ensure that such human tragedies and human defects are eradicated if at all possible. The question should not be what services can we or can we not provide out of rates or taxation but it should be: "Can we as a society devise a system of providing money for health services which will be fair to all concerned and which will ensure that everybody is able to call on full medical services without hardship at a time of need?"
We, in Fine Gael, believe that there is economic capacity within our present national wealth to devise and to apply a health insurance scheme which, with existing taxation and existing or lesser assistance from the rates, would provide our people with the kind of health services which they need. Our people are willing and anxious to pay for a health scheme based on insurance principles. Neither the Minister nor the Government are justified in delaying any further the introduction of such a health service which would provide for the people the kind of services which they, in a developed community, are entitled to. If we do this we will be doing a great thing not only in relation to the financing of the health services but also in the improvement of the services. We should ensure that in so far as possible those who are ill can be cared for in their own homes rather than the present trend which is to send them to costly institutions.
I am afraid that after that marathon my contribution will appear to be one of very short duration. I can only hope that I will make up in quality what I lack in length of speech. Certainly, Deputy Ryan has covered every possible facet of the health services, not to mention things which do not relate to health, but that is his speech and he is entitled to make it.
In the Minister's long and rather detailed introductory speech, when he covered practically everything that could be covered in relation to the health services, he did omit, however, to make any specific undertaking as to when the new Health Bill will be imtroduced. While we are quite willing and ready to wait until after the publication of the Bill before passing any comments on it we, in the Labour Party, had thought that by this time we would at least have seen the Bill. I must admit that we are a little disappointed by the delay.
I am disappointed myself.
Perhaps the Minister has a reason for the delay.
We hope to have it next week.
That is good. We gave permission to the Minister on the 21st January to have the Bill printed.
I have been held up myself.
However, I accept the Minister's word that we will at least have it in print next week. I must agree with Deputy Ryan when he says that it will be impossible to get the new Health Bill through during the lifetime of this Dáil. We all know that the Dáil may be dissolved any time after the introduction of the Budget; certainly, the general feeling within Dáil Éireann itself, in the newspaper world and, indeed, throughout the country is that we will dissolve at the end of May or early in June so that it would be tight fitting to get all Stages of the Health Bill through the House especially if we are to have very long Second Reading speeches and exhaustive Committee work on it. At any rate, let us hope that the Bill will be brought forward. No matter how lacking it may be from the point of view of the Labour Party, we will welcome any improvement on the present position.
In the White Paper on Health, which was published some three years ago, the late Deputy Donogh O'Malley made a couple of points which I particularly noted. One was that no more than the 30 per cent of those not covered by the medical card would be covered under the new Bill and the other was that, where at all possible, a choice of doctor would be available. I read that White Paper in a conscientious and unbiased manner, but these were the only two points of im-. portance that I noticed in it. It is time that a choice of doctor were made available in keeping with the promise then made by the Minister. This is one matter in which the co-operation of the medical profession will be absolutely essential but I will leave this point to be discussed by my colleague, Deputy Dr. O'Connell, who may know more about the subject than I. However, when reading the papers recently I noted that some doctors had grave doubts about the alleged offer made by the Minister to them in connection with night calls and, particularly, night calls in the case of accidents. I cannot speak for the entire medical profession but at least those were the views expressed by those in the profession who wrote to the papers. They felt that the offers were inadequate and the implication was that these doctors might not be prepared to co-operate in the working of the new Health Bill. Let us hope that the Minister will be able to convince them of the need for them to co-operate in the implementing of a health policy and let us hope that the Minister, in turn, will endeavour to do everything within reason to satisfy the medical people because, after all, health is much too important a matter to be measured on a financial basis alone.
I would suggest to the Minister that he would do very well to study the Labour Party's outline of health policy if he has not done so already. One of the points made by us in that document is that the community has the responsibility of providing a free medical health service for all sections without distinction. Its aim is to provide a health service which permits no discrimination between patients and which encourages the maximum involvement of the doctor with his patient.
At present, the health service is administered through legislation and regulations and is based on the concept of different medicines for different income groups. I would be misleading the Minister if I did not find anything wrong with that outlook. The Minister's comment on the Labour Party's outline plan would probably be: "if we could afford it". The question of money should not deter us from providing for the health of the community. Our policy also says that the aim of the Labour Party is to provide free comprehensive health services, free medicines and prescriptions and a free choice of doctor and that the present charges should be dropped. If the Minister would consider those portions of the Labour Party's health policy and endeavour to incorporate as much as he can of it in his own policy he would find that he would merit the gratitude of the people.
Health is so important that finance should not be allowed restrict the provision of health services. Over the past year we have heard of the number of man-hours lost because of strikes. If the Minister investigated the number of labour man-hours lost by ill-health in this country, he would find that they were treble or quadruple the number of man-hours lost by strikes in any one year. I have asked the Minister for Social Welfare, if he is the proper Minister, in a Parliamentary Question to be answered next week, whether he can give me information as to the number of man-hours lost through ill-health by insured workers. I feel when I get the answer from him, if he can get the details, that it will be proved, as it has been in other countries, that the number of man-hours lost through illness and which could be avoided by a proper health policy are in excess of the number of man-hours lost by strikes. The cost of providing such a proper health service would be insignificant compared with the wastage of man-hours in labour. The gain to the State would offset the cost involved.
In the Labour Party policy the question of finance has not been overlooked. We believe that health policy should not be divorced from social welfare. We feel the two are interdependent, and that by tackling the problem of a proper social welfare system one would ultimately lessen the health needs of the country. We believe in graded contributions based on the earning capacity of the people who would contribute. These contributions should be paid into a fund collected through the Department of Social Welfare. Portion of that should be siphoned off to provide payment for health services plus— and this is very important—the direct contribution from the Central Fund out of moneys raised by taxation. We hear a good deal from other Parties about the grievances of the ratepayers and the impact on the rates which, I agree, is colossal, due to the health services. If the Labour Party policy, providing for contributions from all the people paid through a social fund, plus funds from the Central Fund raised by taxation, were in operation, the ratepayers would not be forced to contribute most, if not all, the money.
On the question of drugs, I notice that the Minister in his introductory remarks spoke about control and quality. It may be, and is, very desirable that the proper control and proper quality of drugs should receive his attention. There was one thing I notice the Minister did not stress and it is something very important to the ordinary people of the country. That is, the price of drugs. The Minister and his Department must know that the ordinary middle-group person who has to attend the private doctor is not worried about the £1 or £2 fee for the visit; but the cost of the prescriptions which the doctor writes out may well come to £3 or £4. That may be a continuing process. I had a minor experience of this myself. I suffer from a certain form of fibrositis and have been advised to get vitamin B pills. It means taking a considerable number of them per day. Each of the little, tiny pills handed out from the pharmacist costs ?d. I cannot see the ordinary working man, no matter what his need, being able to follow any course of medicine prescribed by a doctor if he has to meet such charges.
The cost of medicines was a burning question some years ago. Inquiries should be made into the costs of medicines supplied in this part of the country. I am told that in Great Britain and Northern Ireland the very same type of prescription can be made up at very much less cost than it costs in chemist shops in this country. It should be the duty of the Minister to direct his Department, or whatever Department is responsible, to inquire into this. I am not maligning or slandering any chemist, but it is generally believed that this is the position. It should be cleared up whether or not excessive prices are being charged for medicines and drugs in this country.
I am suggesting that, if we had a policy where all the people contributed. 90 per cent of the people in the country would avail of a free medical service if it was there. There might be five per cent or ten per cent who would feel that it was infra-dig to go into a public ward in a hospital. One will always get that type of person. They must have something special, whether it is a specialist doctor or a special hospital or special treatment; but let them contribute and pay the same as the other people and then let them have their specialist attention, which would be their own business. I am sure I would be speaking for 90 per cent of the people in saying that their biggest dread in life, if they are married people with families, is that they might get ill and find that they would have to meet extraordinary charges if they were not covered by some State insurance.
I am aware that I will be told that the Voluntary Health Insurance Scheme is the answer for this type of person but I do not agree with this. The Voluntary Health Insurance Scheme does certainly fulfil certain functions and many a person would be in a very awkward position if he had not availed of the coverage provided by the scheme. However, there are flaws in the scheme and one is in regard to an illness or a disease which is likely to recur and when you go to renew your premium coverage for that disease or illness is eliminated. If you break your leg one year they take a chance that you will not break it next year but if you have had something like rheumatic fever then when you go to renew your policy this disease will not be covered or if you are accepted it will be rather like a motor car insurance and the policy will be loaded.
I do not believe that that type of insurance is worth the contributions necessary to get full coverage. Another point about which I have no knowledge but which is common property among people who had the misfortune to be in hospital and who had the good luck to be covered by voluntary health insurance is that charges made by hospitals, whether they are local authority or voluntary hospitals I am not quite clear, are levied in direct proportion to the number of units which the patient has. If the patient has a small number of units the charge is low but if the patient has full coverage the charge will be put up to the maximum. This has been said to me so often that I have every reason to believe there may be some truth in it. It may be of importance to the Minister, if he is satisfied with the value of the Voluntary Health Insurance Scheme, to have investigations carried out to see if this practice is operated in certain hospitals.
It is only in regard to medical fees. The hospital charges do not vary.
The charges to the patients certainly do. The bills coming from the hospital vary.
Only the medical fees.
Perhaps, they are from the doctor or the surgeon.
The hospital charges are constant.
But the medical fees vary by the number of units you have.
(Interruptions.)
You may not agree, doctor. I am quite well aware of that.
You know what happens when doctors disagree.
Patients die. I am sure the Minister is tired of hearing about the impact of health charges on the rates. On average, one-third of the rates of the various counties is directly attributable to health charges and there is a great demand by councillors that at least 75 per cent of the charges should be met from the Central Fund. The Labour Party policy seems to cover that but whether that would be acceptable to all councillors who want the charge taken off the rates is another matter. The Minister's circular appealing for a pruning of the health estimate received scant attention by most health authorities and county councils. There is a difference between health authorities and county councils in some areas like Dublin, Waterford, Cork and Dún Laoghaire where you have corporations and, therefore, different representation.
The managers and officials pointed out to members that not only can no saving be made but up to 20 per cent increase should have been made because of changes since the original estimate was proposed in November. The 20 per cent is due to increases in food, wages and other things which have all gone up. There is little hope of the Minister's suggestion that local authorities should prune the present estimate being realised and deputations to him will be seeking greater contributions from him in order to reduce the amount of money levied on rates.
I read recently where Dublin is expecting a considerable increase in the grant in regard to health. If the Minister does that for Dublin possibly he will do it for the rest of the country. Certainly, it would be very welcome because rates have gone beyond the limit. However, because of the change in the value of money I cannot see rates coming down in any period in the future, rather are they likely to go up. As one who has always demanded the best services for roads, health or whatever else it might be, I have no real objection to rates going up because you cannot have these services without paying for them. If the value of money is changing the charge for services which we got in the past will be increased automatically.
One subject which is very dear to my heart is the question of conditions and pay of nursing staff in local authority and voluntary hospitals. In the past I have said that nurses are the Cinderella of the medical profession. There is no doubt that the pay, conditions of service and hours of nurses are abominable. In my area, through the efforts of the trade union movement, we organised attendants and brought up their pay so that now very often their pay is higher than that of qualified nurses. This is not because the pay of attendants has been increased greatly but because of the shocking pay of qualified nurses. I wonder if the Minister is aware that any qualified nurse who leaves for America can get £2,500 per year for an eight-hour day and if she works an extra shift of eight hours she will qualify for another £14. I am quite sure I am not far out in saying that the average nurse in local authority hospitals, and possibly in the voluntary hospitals, has less than £10 a week.
In regard to hours, the Minister may say that they are fixed and certainly they are, but if a nurse in a local authority hospital is on duty from 8 a.m. to 4 p.m. and if an ambulance call comes in at 3.30 very often she is sent out on that call. She must do without food for as long as the ambulance is out, which sometimes in winter can be three, four or five hours. Instead of being paid overtime she is told: "We will give you time off when we have an opportunity, when we can do without your services". This is not proper treatment. Deputy Ryan spoke about a scarcity of nurses. Why should nurses stay in this country to work under those conditions with that sort of pay? If nurses were organised into proper trade unions I am quite sure those conditions would be changed. The weakness of the nurses is that they look on their job as a vocation and not as a means of living. Their only reward for that is that it is accepted as a vocation and they are paid miserable rates. I should like if the Minister would indicate to me what round of wage increase local authority nurses are entitled to at present. In some local authorities, of which I have knowledge, nurses are awaiting a decision regarding certain pay increases. Whether it has been made by the Minister or not, it certainly has not been implemented by some of the local authorities.
The Minister spoke in his introductory statement about Dundrum Mental Hospital. I had Parliamentary Questions down to the Minister asking him whether or not he would bring Dundrum Mental Hospital under the control of the Dublin Health Authority. I notice from his introductory remarks that it will now be linked with the Dublin Health Authority. Does that mean that the staffing arrangements will come under the control of the health authority? Does it mean that the medical staff will be serviced from the pool of available medical people in the Dublin Health Authority?
I am told—again I must rely on hearsay—that there is a large number of unqualified male attendants there and that the number of qualified male or female nurses is inadequate for the number of patients. It is felt by the parents of people who have the misfortune to be inmates or patients there that the nursing is being carried out by unqualified male attendants and that much benefit would accrue from bringing the hospital under the direct control of the Dublin Health Authority. I trust that what the Minister calls the link with the Dublin Health Authority will achieve this objective.
I have no desire to attempt a marathon speech on this Estimate. I should like to say in conclusion that any improvements the Minister brings forward next week will be welcomed by the Labour Party because any step forward is better than remaining where we are. We may not agree with the full contents of the Bill, we may argue for an improvement in the Bill, but we will be satisfied with any improvement especially the one indicated in the White Paper, that is, the choice of doctor, where that is possible. We will have to wait until some Government implements the Labour Party policy as outlined in our policy statement before we will be completely satisfied that we have the correct health services for this country.
I should like to support the adoption of this Estimate and to compliment the Minister on going into the question in such a thorough way, giving us statistics concerning the work of his Department during the past year and covering such a wide range of items relating to the private and public health of the country. The Minister, his Department and the county medical officers of health must be complimented on having such a high degree of good health throughout the country. Very rarely do we have an outbreak of any disease such as occurs in other countries not so far away from us. It is due to the keeping of a good eye on general health procedures that we have this good health.
One thing that is confusing for people, particularly the lower income groups, is the general medical card. People find it hard to find out what the limits of income are in order to qualify. The local authorities could do a good job by spelling out specifically the rates they work on. I know they have figures but they do not seem to like to release them. It would put people's minds at ease if they knew whether they were inside the range or not. I know there must be exceptions so that people with a higher income can be taken in where there is a good deal of recurring sickness. There cannot be hard and fast rules, but in the ordinary case of a family in good health there should be no secrecy about it. I hope when the Minister brings in the Bill next week there will be something in it to advise local authorities to inform people generally who is entitled to free medical service. I feel the public are entitled to know this. It is frustrating not to know why they are being turned down, just to get a letter saying their means are over the limit and they do not know what the limit is.
I was very pleased to hear the Minister in his speech dealing with the care of the aged. It is one aspect of health of which most people are conscious. Some of these people like to be on their own but they also like to be near to the people with whom they have been living all of their lives. I am glad, therefore, that the Minister is about to enlarge the district health nursing service and that through it people in localities will be encouraged to visit and look after old people. I know areas in my constituency where the communities are very good at this work.
For instance, there is hardly a parish in the constituency where there is not a Christmas party held for the old folk. The people raise funds for the entertainment of old people and the result is that whenever I am talking to these old people they are either looking forward to an old folks' party or speaking about one they have been at a few days earlier. These functions impress on these old people that they are still active members of the community, that they are integrated in it and that they are not forgotten. One of the worst feelings an old person could have is that he is forgotten, that nobody has time for him. Nowadays they feel more important when they find that so many people are interested in going to see them.
Therefore, any extra assistance the Minister could contribute towards the care of the aged would be very welcome. From an economic point of view it would be less expensive to care for such people in smaller establishments than to send them to county homes. The Minister gave a figure for local authorities' expenditure on county homes and the cost it would be to bring them up to date. It is another aspect of the health services. Not only did some of the old county homes carry a stigma but physically they were gruesome and dreary. I have seen some of the new homes being built and they are bright and airy but they still cater for too many people. I have seen some of what I might describe as private homes and I understand that the charge in them would be about £2 more per patient than in the county homes. I am taking the cost of my own local authority in this instance: I know the cost to the local authority and I know the cost per patient in these smaller homes. The Minister seriously should consider encouraging local communities to establish such small rest centres, catering for 20 to 40 people. Old people are happier in smaller groups and we should try to encourage local people to set up a number of small homes throughout the county. In that way we would be giving a better service and keeping well within our budget.
I mentioned that there is a gap of only £2 between the cost of keeping a patient in smaller homes and in county institutions. I feel sure that if the Department said to a religious community: "We will guarantee to keep your home full; we will give you 75 per cent of your patients for a whole year", a bargain could be struck and such a religious community would cater for these people at the same cost as the county homes. It will take a long time to educate people out of the county home stigma and we should consider as well the advantage that in smaller homes the old people would be nearer to the community in which they have lived.
There is the added advantage that in smaller homes, spread throughout a county, the patients would be nearer to their friends and relatives for whom it would be easier to pay frequent visits. In Kildare, the county home is at one end of the county and often people who wish to visit old people have to travel 40 miles. In Meath, the county home is more reasonably centred but if there were, say, three small homes in each county, run by a religious community, it would be far better for all concerned, particularly for the old people.
Progress reported; Committee to sit again.
The Dáil adjourned at 5 p.m. until 12 noon on Wednesday, 19th March, 1969.