One of the primary reasons for my intervention in this debate is the report of the consultative committee on the general hospital services of the future and the hospital system. I certainly hope that what is contained in this document is not given effect to, otherwise there will be consternation throughout the land. If one relates this report to one's own constituency or to the health authorities in one's own constituency one is appalled at what could happen if effect were given to it. It contemplates a radical change in our health services. The regionalisation of the health services is to some extent understandable but one realises, in respect of South Tipperary and, indeed, in respect of County Tipperary at large, that if the FitzGerald Report is implemented it involves leaving all County Tipperary without its own hospital service; it means the closing down of the main hospitals in the county, in Nenagh, Cashel and Clonmel and also the smaller hospitals at Carrick-on-Suir, Clogheen and Tipperary.
This report has shocked and appalled the public representatives on South Tipperary County Council; they are appalled at the prospect of all our patients being obliged to go for treatment to places like Limerick, Cork and Waterford. It may be argued that these regional hospitals are within reasonable proximity to various points in our counties but the mind boggles at the thought of a chronically ill patient being transferred from Clonmel to Limerick or Cork. Apart from that there is also the problem of the relatives visiting the patients. They would be unable to visit patients in such far away places. The cost of travel in this country is very high and it would be extremely difficult for relatives to visit patients in these places at regular intervals. My colleagues of all political affiliations in the South Tipperary County Council and its subsidiary bodies and of the North Tipperary County Council and its subsidiary bodies are unanimous in our outright and positive opposition to the FitzGerald Report. We will never allow it to come into operation in our county. We will never allow the hospitals which we have improved and developed at such considerable cost to be closed down or relegated to the status of what are called community health centres.
I do not know what a community health centre is. I presume it is a clinic where people will go for inspection or for outdoor treatment. It is appalling to think of our hospitals being degraded to this status and our smaller hospitals being closed down. While we are most concerned with efficiency we will never accept what is contained in the report with regard to the wiping out of the whole hospital service of County Tipperary and the relegation of our people to faraway places for treatment.
I understand that the Minister has accepted the report in principle but he would need to be very wary before he commits himself to implementing it in its entirety, especially in Tipperary generally and in West Waterford where we are outrightly opposed to the suggestions contained in it. I would hope that before any of the recommendations of this report are embarked upon the members of the local health authorities would be given the courtesy of consultation in advance, that the Minister would consult with us before implementing the radical aspects of the report so that there would be some degree of co-operation.
The closing down of our main county hospitals cannot be condoned in any way. These are institutions which have been extensively and expensively improved over a long number of years. Under the British system there used to be poorhouses or almshouses but they were transformed into modern hospitals, highly staffed and equipped. We are intensely proud of the work done by our county managers and our health officers in transforming them into the finest institutions in the country and we will not see them closed or relegated to the status of community health centres by a stroke of the pen by Mr. FitzGerald or anybody else.
Most other Deputies will have been as alarmed as I have been and in this matter I am calling for the determined opposition of all political Parties in South Tipperary to the idea of closing down the wonderful surgical hospital which we have at Cashel. This is where, in the main, all the surgical treatment in South Tipperary is carried out. Closing down the County Hospital in Clonmel, which is essentially a maternity hospital and a general hospital, and closing down the general hospital in Nenagh would be nothing less than disastrous and no sensible public representative could condone or have any hand, act or part in such an action which would have farreaching consequences for the large population involved.
I want to avail of this opportunity to pay tribute to our nurses and the wonderful type of nurse we have. It is not a vain boast to say that our nurses are the finest and most dedicated nurses in the world. It is the wish of myself and my colleagues that we should appreciate our nurses fully and ensure for them the very best conditions of employment, respect their high standard of education and ensure that their remuneration is suitable to the outstanding work they perform. We would also wish that they should have suitable avenues of promotion open to them and that nurses returning from British hospitals should receive full credit for their cross-Channel nursing services. It is to be regretted that so many of our girls must go to Britain to be trained as nurses and I would ask the Minister to do what he can to provide more opportunities for training nurses in our own institutions. Many of these girls do not go to Britain for training of their own volition but because the opportunities are not available here. Naturally, having qualified, they very much desire to return and to work in our own hospitals. They should be welcomed with open arms and the high degree of efficiency and skill which they acquire in these wonderful hospitals in Britain should fully be appreciated. We can best do that by ensuring for them conditions and remuneration commensurate with their skill, training and education.
I should like to see our nurses having the same opportunities for promotion as are available in Britain and elsewhere. There should be no restriction in regard to promotion and I would ask the Minister to ensure that nurses in our hospitals, our lay nurses, are afforded promotional opportunities to all grades up to the full status of matron. I would like to see this being possible even where a religious order is running a hospital. The Minister can say whether or not this is true but it is alleged that no matter how highly qualified lay nurses may be they cannot obtain promotion in hospitals run by religious orders unless, it is also alleged, they join the order. This is not intended to denigrate in any way the wonderful work of these religious orders in our hospitals but it is only fair to the nurses concerned that in any sphere of their employment the opportunity for promotion should be there. One can well understand how utterly frustrating and disappointing it must be for a highly qualified nurse, who has devoted her life to this noble profession, to find that she may never be able to become a matron in one of these institutions. I should be very glad to hear the Minister's views on this matter. I feel that we will continue to lose some of the finest brains in the nursing profession if there is not a change in this regard and unless there is this promotional opportunity for them in the future.
I want now to pay tribute to the Jubilee nurses. This wonderful nursing group has now virtually disappeared and it is a great pity. Their origins were essentially British but, be that as it may, we remember with pride the wonderful work they performed throughout the country when our health services were even worse than they are today and these gallant ladies moved through the sick poor operating as angels of mercy and being of wonderful assistance to the local dispensary doctors. They did herculean work for our people and their going leaves a void which it will be difficult to fill. Indeed, in places where the Jubilee nurses have already disappeared we have as yet been unable to replace them, certainly in parts of my constituency. The Minister will have to concentrate on speeding up the provision of many extra district nurses to fill this gap caused by the disappearance of that wonderful institution, the Jubilee nurse. The group was financed by the donations of local people and perhaps by a contribution from a local health authority. Their position was precarious and they had no semblance of security at all. It is a wonder they operated so long in such difficult circumstances. It is a pity they were not merged properly in the reorganisation of the health services in recent years and properly compensated for a lifetime of endeavour for our local communities especially in respect of pensions and the like.
The Minister is to be commended for the interest he has displayed in the welfare of the aged. It is a good thing that he has empowered local authorities to make grants available to deal more effectively with the problem of the aged. No doubt the health authorities throughout the country will rally to the Minister in this regard and interpret his wishes in the spirit in which he intended, to provide generously moneys for all those wonderful voluntary organisations which are doing such wonderful work for the care of aged people. It is high time they were recognised by the Department of Health and its Minister. I know the local authorities will be only too pleased to make available the necessary money for the purposes intended.
How much worse off the health services would be and the standard of living of these poor, aged people were it not for the outstanding work being done by these voluntary organisations? How many more of these aged people would wind up in the county homes? The county homes of this country would be cluttered up and overcrowded altogether were it not for the efforts of these voluntary bodies in providing meals on wheels, visiting regularly, providing comfort in cash and kind and making it possible for these old folk to live at home. This is the truly wonderful aspect of this matter, the many thousands of people throughout the country who have been afforded the grand opportunity of remaining at home whether they lived alone or with relatives, by the efforts and the sympathies of these voluntary bodies in providing the meals on wheels, in providing money and coal and comfort by their visits. Therefore, it behoves us all and especially the State to supplement the old age pension or the widow's pension, whatever the small State pension might be, by generous allowances whether it be disabled persons maintenance allowance or home assistance or special grants of this kind.
I feel that however much we spend on the transformation of our county homes we are not making them any more attractive to our old people nor, indeed, to their families. My experience, as a public representative, is that there is still this ingrained reluctance to permit of one's relative being despatched to the county home no matter what kind of fancy name we append to it. This old stigma is still there. Consequently, the work which the Minister is laudably helping in is to be encouraged and promoted in every way.
After that I would hope to see us providing more adequately for our geriatrics as they are known by the provision of a number of beds in all our local hospitals rather than concentrating on the building of a grandiose county home, providing a home for the old folks in their own environment. I think the most practical idea would be the provision of additional beds at the local hospital, even if it were only ten beds, for geriatrics. There they would be in their own environment and could hope for visits from their friends and relatives much more often than if they were sent to the county home.
I was concerned about the recent circular which the Minister issued to all health authorities. Instead of getting the good news from the Minister that he was increasing the subvention for the health services this year in conformity with the increased wages and salaries and costs of all kinds, we had a rather worrying letter issued to us laying down strictures of economy which we were all obliged to conform to. The Minister may not have intended it that way but when one talks about economising in respect of the health services or the provision of proper health services for the local community one can hardly be expected to economise unless one is forced to cut back on the services. A cut back on the health services is something which none of us could condone. Is it seriously suggested that we should cut back on the cost of medicines and drugs? Is it seriously suggested that we should cut back on the subventions which we are entitled to pay to private institutions? Is it suggested that we should adopt a get-tough line in respect of the provision of medical cards? God knows the line is tough enough and the means test odious enough without inculcating into the minds of managers or officers of health authorities the idea of getting tougher still and cutting back on health services which, even at their best, leave a lot to be desired.
I observed that in the Minister's speech he particularly mentioned that the cost of medicines has increased considerably since the scheme of free drugs and medicines was introduced. This is quite true.
However, it is also to be appreciated that these free drugs and medicines were designed to assist people in the middle income group who would not normally qualify for a medical card, who would have a sick patient on their hands for a long period and for whom it would be a financial burden which they simply could not afford. It is right and moral, equitable and just in these circumstances that free drugs and medicines should be provided. They are so being provided by most health authorities in these circumstances.
It is appreciated that the cost of drugs and medicines is exorbitantly high in this country and, perhaps, in most countries. It was hoped that the Minister would tackle this problem energetically and effectively and would clamp down on the obvious exploitation in respect of the cost of drugs and medicines, the excessive charges, the obvious colossal profit which the manufacturers are making. It is difficult to understand the variation in the cost of these commodities and the fact that the State is so helpless in trying to grapple effectively with this problem and to bring costs down to more rational proportions.
Local authorities cannot be expected to get their medicines and drugs on the cheap. We have to be very careful about providing health services on the cheap. There is already a feeling that too much of our health services is based on the criterion of money rather than actual need. There are various grades of health service and medicine as between the private ward, the semi-private ward and the public ward. It is generally felt that there are various grades of treatment for varying classes of patients. It is an acknowledged fact that everybody does not experience the same bedside manner as is displayed towards the paying patient. That is distinct from the grunt and the growl which the holder of the medical card may get from the same individual.
Therefore, we had hoped that the Minister would have implemented a free choice of doctor. It is intrinsically wrong that a medical card holder should be condemned interminably to the same doctor. There ought to be a choice. Is it not a fact that the right of choice of doctor is so ingrained in people that even the very poor who have medical cards in some cases do, in fact, go to a doctor other than the dispensary doctor and pay their £1 for this right of choice? Is it not a fact that quite a large percentage of medical card holders do not attend the local dispensary doctor but feel obliged to exercise a choice and pay the local doctor and secure the drugs prescribed at the dispensary in the ordinary way? This choice of doctor is fundamental and should be conceded without further ado.
The Minister should take steps to liberalise the rigid means test applicable in the case of medical cards. He should eliminate the embarrassment and humiliation involved in seeking a medical card. There is the odious means test carried out by home assistance officers in which the entire family income is calculated. As a result, an applicant may be told that he is exceptionally well-off and his application for a medical card is rejected. The late Deputy Donogh O'Malley said in the White Paper that he produced that he would liberalise this test, that he would exclude the income of certain members of the family in the calculation. That promise has yet to be fulfilled.
In the area that I represent I observe that members of the Defence Forces, our soldiers, are, in particular, victimised by this odious means test for the purposes of medical cards. I put it to the Minister that it would be a worthwhile exercise to ascertain the number of Army personnel, in the grade of private in particular, who hold medical cards or whose medical cards have been withdrawn. It is a very niggardly test, indeed, which determines that an Army private with a wife and a large family is not entitled to a medical card. I know for a fact that where Army privates and their families held medical cards, the cards have been withdrawn. An army private or corporal may have access to excellent medical treatment from the Army but that treatment is not available to his wife and children and they are the sufferers. I know it to be a fact that the wives and children of Army personnel are suffering great privation and hardship in recent times as a result of the denial to them of proper health services by reason of the withdrawal of medical cards or the persistent refusal to grant medical cards to these categories.
I raised questions in this House with the Minister for Defence. The Minister for Defence is not concerned about this matter. The Minister for Health will probably tell me that these people are subject to the same means test as is applicable to other citizens. I choose to think that the wage or salary of an Army private is not so high that he and his family should be precluded from having their names on the health register as such. I would ask the Minister to consider this situation. It is a matter of very grave concern to me that so many Army privates and their wives and families in particular should be in a state of desperation as to how to provide money for doctors' fees, drugs and medicines and hospitalisation. I maintain that their standard of living is not so opulent that they can be regarded as being in the middle income group.
I want to lend my voice to the pleading in this House for a more humane approach to all those unfortunate people in the lower income group who are dependent on the dispensary services. There is no proper accommodation provided for them. We have had to raise this matter here before. Many of our dispensaries are in a scandalously dilapidated and ruinous condition. They are cold, damp and dark, and, apart from all that, there is no privacy provided for the people who have to avail of them. These places are utilised for many purposes. Apart from their use by the dispensary doctor and nurse, they are also used by home assistance officers, rate collectors and the like. Many of our people are humiliated and greatly embarrassed by the appalling circumstances prevailing in these dispensaries.
The Minister should seek an improvement in these premises. We must have due regard to the dignity of the human person and ensure that the same kind of treatment is given to the medical card holders as to the person with a big fat wallet. Admittedly, if we get the choice of doctor which is envisaged in the White Paper it will mean the withering away of this dispensary service. Knowing what the people have to contend with when they queue up at the local dispensary for a check-up by the doctor and the provision of the proper treatment by way of drugs and medicines, I am quite satisfied that the old red ticket system of many years ago under the British regime was a far more honourable system than the present one. The present system degrades and humiliates a person from the very onset of the investigation, from the moment a person enters a dispensary and queues up in the cold dilapidated atmosphere, to the manner in which the drugs and medicines are dispensed and to the treatment afforded in the public wards of hospitals as distinct from the semi-private or private wards. Under the old red ticket system, you merely presented yourself for the ticket and you got it without question. There was no means test. Need was the criterion, not money as is the case now.
The Supplementary Estimate, therefore, has been a shocking disappointment to us all. We are all regarded as astute politicians, and it was rather expected the Minister would avail of this unique opportunity of giving us a general election Health Estimate — that the least he would do would be to make good the promises made in the White Paper on the Health Services to provide a choice of doctor, to liberalise the means test for the medical card and abolish this dispensary system of which I have been talking. It was also expected that he would rid the local taxpayers of the crushing burden on the rates and make the cost of the health services a charge on the Exchequer. In getting rid of the burden as ratepayers we know we shall have to meet it as taxpayers, but we contend that the raising of this sizeable amount of money for the health services by way of direct taxation is a far more equitable system than raising it through the rates. I hope, therefore, that the Minister will take his courage in his hands and indicate as soon as possible to all our health authorities that he will make the health services a charge on the Exchequer.
All of us who are members of health authorities are anxiously awaiting an announcement by the Minister in this regard. I represent part of County Waterford; in fact I am as much a Member for West Waterford as I am for South Tipperary. Naturally I am very familiar with the affairs of Waterford County Council and I think that council were right when they refused to strike a rate in recent weeks. They realised that while they have an obligation to strike a rate they also have an obligation to strike a rate which their people can afford. The increase in the rate in County Waterford has been such that they felt they would not be justified in passing it on to the people at large. They have declined to strike a rate until such time as the Minister makes known his decision on the contribution he proposes to make to the health charges.
Much has been done but much more remains to be done in respect of mentally and physically retarded children. I am concerned about the interminable delay before proper institutional treatment can be provided for so many of these children. The Minister is giving attention to this matter, but we are depending, in the main, on the religious orders, to whom I wish to pay tribute for the wonderful part they are playing in grappling as effectively as they can with the problem of the mentally and physically retarded. We have not advanced very far in regard to health matters generally when institutional treatment cannot be provided for these unfortunate children except after most strenuous efforts and after waiting for years for bed accommodation. The position has become much easier in securing proper institutional treatment for the mildly handicapped but it is still extremely difficult to secure proper institutional treatment for the severely handicapped. I do not have to elaborate on the sad, sorry situation in any household where there is a child of this kind and the great tragedy of it. We realise the impossible task of coping with a patient of this kind in the home and the great cross which parents and the family at large have to bear.
I would ask the Minister to have a very close look at this situation again to see what he can do to accelerate the provision of bed accommodation for these unfortunate people. It is a serious indictment of our institutional services at large that so many of these severely mentally retarded boys and girls of very tender age — 11, 12, 13 years — are finding their way into our mental hospitals and are domiciled with adult male or adult female mental patients. It is an intolerable situation and the Minister ought not to condone it. He should see to it that steps are taken to ensure that no mentally or physically retarded child under, say, 18 or 20 years is permitted to be domiciled in a mental hospital. It is utterly unsuitable for this purpose and there are grave dangers attendant on their being based in such an environment.
I want to avail of this opportunity of asking the Minister, if he has not already done so, to extend the school medical service to children at post primary level. It is intrinsically wrong that the service is not continued once they leave the national school. Whether it be treatment of the ear, nose, throat, eyes or anything else, it will have commenced in the primary school but parents find that the free treatment will not be continued while the child is attending secondary school or vocational school. I appeal to the Minister to ensure that school children, irrespective of age, are given this free medical treatment and that this silly business of stopping the service at national school level ends once and for all. It is a matter of very great concern to parents that this anomaly in the health services should be rectified without any further delay. It is surprising that we have to mention it so often in this House. It is a reasonable request and it is so obviously necessary that it is difficult to understand why it has not been implemented long ago.
I want, also, to express my concern about the difficulties of securing certain specialist services and, in particular, about the difficulty of securing dispensary doctors in certain parts of our country and in certain parts of my constituency. As the Minister and his Department are well aware, we are finding it extremely difficult to secure a permanent dispensary doctor at Ballingarry, Thurles. The people there, especially the medical card-holders there who are entitled to the dispensary service, free drugs, medicines and the like, have been bereft of these rights for some considerable time past as a result of our inability to provide a permanent doctor and dispensary service there. We have a temporary arrangement and the doctor concerned is doing the best he can, but it is utterly and totally inadequate. The large number of people in this dispensary district are in a truly bad way for a doctor. They have to travel long distances for a doctor and they have to pay dearly for a doctor even though they have medical cards and are entitled to this facility free.
One can imagine the anxiety of mind of the large populace in the Ballingarry area, a renowned mining area. Mining is a dangerous and precarious occupation. There goes with it a pretty high incidence of accidents. These miners and their families, farmers, workers and people at large in this area have had no permanent doctor living with them and serving their needs for some considerable time. No words of mine can adequately express their anxiety, their constant worry, their ingrained fear of ill-health — their fear of a pain in the middle of the night, their fear of accident and their fear of the known virtual impossibility of securing a medical practitioner within a reasonable time.
I know this matter has been before the Local Appointments Commission on many occasions and that they would seem to have recommended somebody for the post but nobody ever took up the post. I do not know what is wrong. If it is a matter of inadequacy of salary, this I think would be a function of the Minister. We, as a health authority, have done our best to make the post as attractive and as lucrative as possible. We are concerned lest the trouble might be that of accommodation. We have now provided excellent housing accommodation as well as an excellent dispensary, duly repaired and modernised, in the hope of attracting a permanent appointment of the kind we desire.
Recently, I wrote to the Minister asking him if he would be good enough to receive a deputation in respect of this very important and very urgent matter. In due course, the Minister replied to my letter under his own hand. We are all politicians and supposed to have thick skins but I believe the Minister set out deliberately to be outrightly discourteous to me in the reply he caused to be issued to me. Not alone did he fail to reply to my query as to whether he would receive a deputation but he went on to tell me about the part which other politicians played in this matter of bringing to his notice the position at Ballingarry. Obviously, the letter was couched in such terminology as to ensure that I would derive very little political kudos out of it. I can find political kudos in many ways without seeking to make a mockery of the sufferings of the people of Ballingarry as regards their lack of doctor and proper dispensary services——
