Dáil Éireann debate -
Thursday, 20 Mar 1969

Vol. 239 No. 5

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

Debate resumed on the following motion: "That the Estimate be referred back for reconsideration."— (Deputy Ryan).

Mr. Moore

Last night I mentioned the fact that there were many hospitals in the city of Dublin and elsewhere which are very old and on which we spend a lot of money. Instead of patching up broken bodies we are patching up old and derelict buildings. This costs a tremendous amount of money which in some cases is waste.

The Minister, who has pressed very hard for an improvement in the general position of the health services, two years ago set up a consultative council on the general hospital services. They brought out a report in a very short time entitled "Outline of the Future Hospital System." This body, which examined the whole position, included some of the best names in Irish medicine. The report cost £4,000 and it was worth it because in it there is good reading of the history of medicine in Ireland. One finds it very interesting.

On page 17 of this report there is an indictment of the hospital position today. At paragraph 2.14 it says:

There are altogether 169 separate hospitals providing acute medical, surgical and maternity services. Most of them are inadequately staffed and equipped. In County Hospitals, the single consultants in surgery and medicine are isolated from colleagues in their fields.... The older hospital buildings are unsuitable for remodelling while the majority of the modern ones were planned on too rigid and too restricted a scale to permit satisfactory conversion.

Here is a facet of the health services which must be tackled sooner rather than later if we are to improve the general health services and reduce the great amount of waste which is taking place not through the fault of the administrators but simply because they are handicapped by the buildings which have been handed on to them. Some of these buildings were built in the eight-teenth century and while they have been vastly improved in the meantime many of them are practically falling down. I suggest we should pull them down and go for modern buildings. It will pay dividends by an improvement in the people's health and also financial dividends.

In the city of Dublin there are slightly over thirty hospitals. Most of them are voluntary teaching hospitals. Big changes are planned in the set up of some of these hospitals. I do not think there is any local authority hospital in the city which is also a teaching hospital. Perhaps this is a pity. While the traditional schools in Dublin, Cork and Limerick are the voluntary hospitals and while we must retain this pattern we must also recognise that the local authority hospitals often have better facilities for teaching than the voluntary hospitals. The Minister might look at this matter and see if St. Kevin's and St. Colmcille's could be given the status of teaching hospitals in some degree. We are jealous that the voluntary hospitals be maintained in our scheme of things because of their work in the past, because of the work they are doing at the moment and will do in the future.

This report is a most interesting one and the more one reads it the more one finds in it material for thought. On page 65 the proposition is put forward that we should not have specialist hospitals built in isolation, that cancer and eye hospitals should be part of a major hospital complex, all in the one building. They say that if we had these specialist hospitals in the one building it would be better for the patient, the doctor and the economy in that order. I am sure the Minister will look into this. Then we also have the position where consultants are not paid fees in voluntary hospitals but are given a certain number of beds in these hospitals and, by charging their wealthier patients, can get some return for their services. That is all right where the patient is not a clinical patient but a pathologist, for instance, could not get fees in these circumstances. In the 1963 Health Act we made provision for specialists to get a capitation fee but in these modern times this is not the best way to pay them for their services. I hope this matter will be examined in the new Health Bill.

When we speak of our hospital staffs we must also speak of our nursing staffs. We know it is difficult to pay trained nurses, who are so dedicated to their work, adequately for their services. However, we must ensure that the women who enter the nursing profession are paid salaries commensurate with their standard and the skill of their profession. All these things might cost money but the Minister has never been remiss in his attitude to the nurses and the nursing profession and we know that in the matter of payment they will have his sympathetic and expert attention.

The cost of our health services is vast and is mounting all the time. Last week Dublin Corporation asked its Deputy members to see the Minister and ask him for some remission of the health burden on the Dublin rates. It may be asked why should Dublin merit any special attention, why should not Cork or Limerick or Waterford get similar relief. A capital city like Dublin is a very special case because of the fact that the number of patients from outside areas treated in its hospitals is very great. Very often local authorities, unless they have sent a patient direct to our hospitals, will disclaim any knowledge of him. The hospitals must keep him and treat him and the Dublin Health Authority must pay a capitation grant for that case.

In a city like this we would not refuse hospital treatment to anyone but the Minister should have a look at the figure of over £200,000 which I have already mentioned in relation to capitation grants. This would be a gesture from the Government and the State to the work being done in the Dublin voluntary hospitals and it would show the people that, while we take pride in our hospitals and medical schools and are willing to pay for them, we would also like some extra help towards maintaining this vast hospital complex. It may be thought that to have over 30 hospitals is a good sign but it is not always easy to get a bed in any hospital. For over 700,000 people over 30 hospitals is a fine ratio but if we grouped the whole complex we would find ways of perfecting the system and make it better in terms of service to the people who need treatment. I would ask the Minister to consider, before next Monday if possible, if he can meet Dublin Corporation in any way about the colossal health impost on the rates.

When a person who has not a medical card needs attention he may find it an almost intolerable burden to purchase the drugs and medicines prescribed by the doctor. In this connection I would ask if any progress had been made in the bulk buying of drugs for distribution to retail chemists so that there will be some reduction in price to the person who has not got a medical card. Under section 54 of the Health Act we can help if the drugs are prohibitive in price and perhaps the time has now come when we should further extend our help in this aspect of our health services.

The local health authorities are doing tremendous work in improving the health of the people. The report of our city medical officer for 1967, the last year for which a report is available, details the work of the health inspectors. In one year they inspected 47,000 houses and 101,000 rooms. In many cases the landlord carried out remedial repairs. This may seem to be outside the ambit of the Minister's Department. It is not. We have long recognised that good housing is essential for good health. We must pay tribute to our local health authorities for the work they are doing. The point I wish to make about these health authorities is: Is this the best system we can devise in order that the health services at local level may carry out the job they are designated to do? When the proposed Health Bill comes before the House there will be many suggestions and proposals put forward as to how to perfect the health services. Therefore, I shall conclude by complimenting the Minister on the work he has done since he took over the Department and on the Estimate he has introduced. I look forward to the introduction of a new Health Bill which I am sure will represent a big step forward in improving our health services which some people claim are inadequate. I do not say that they are inadequate although I am very conscious that there is room for great improvement.

Mr. Coogan

On all sides of the House concern has been expressed about the increased demand in the rates under the heading of health. I suggest that the cause of this increase in the rate for health was the implementation of the turnover tax. The turnover tax reflexes itself in all facets of health institutions. There is the increase in the cost of medicines, food and everything that goes to the running of a hospital. There are the increasing demands, rightly, of workers and medical staff as a result of the increased taxes. All this is reflected in the increased rates.

I come from an area where we have reason to be proud of the health services, doubly proud of the fact that our hospitals were built during what Fianna Fáil say were the nefarious days of the inter-Party Government. I can remember a time when there were patients lying in the corridors of the old workhouse that was converted to a hospital. Many got pneumonia as a result of the draughts in these corridors. I can look back with pride to the day when, after the inter-Party Government came in, we laid the foundation stone and built a hospital that is second to none in this country. Likewise as far as Merlyn Park is concerned. I remember seeing hospitals for TB patients which were a disgrace to a Department and where unfortunate doctors had to work trying to stem the great inroads being made on the health of the people by TB. I saw the grandest young men and women wiped out by TB prior to the advent of the inter-Party Government. I look back with pride to the day when an inter-Party Government took action and called a halt. We are blessed by having a hospital but a hospital is a building and what is a building without good staff? I am proud to say that we have the best staff in this country in our hospital. That goes from the top down to even the white belt young nurse. The service is one we can be proud of.

I should like to pay tribute to the religious and the voluntary organisations for their work for the infirm and mentally handicapped. I hope to see this work being extended. There is a great demand for it. There are many unfortunate cases that could be dealt with. But for the great work of the religious and voluntary organisations we would be in a sad state today.

I have heard Deputies talk about hospitals and the great work being done. Let me remind them that only for the Irish Hospitals Sweepstake which was initiated from our Party and which was frowned on, there would be few hospitals in this country today. This is something that has been forgotten. I should like to let the people know that this is not a onesided effort.

I have referred to the turnover tax and its effect in increasing the cost of our health services. We all remember a promise made by a former Minister as to how the increased rate for health would be met. I should like the Minister to let us know, when he is replying to the debate, what he intends doing about this promise. Does he intend to implement it or does he want the people to accept the crushing blow, brought on by Government mal-administration, of increased costs? Is the Minister going to do something to meet this burden of rates?

I should like to compliment those concerned with the Voluntary Health Insurance scheme on its success. The people should realise the importance of this scheme. This is another of the things that we brought in. It is no harm to remind the people opposite of all these things because they are sitting there enjoying the kudos that flow from them.

From all sides of the House mention has been made of the medical card system. To say the least, it is degrading. It is brought down to the level of the blue card and the bullock, the only difference being that you do not have to plug the ear of the unfortunate medical card holder as you do in the case of a bullock. That is the one saving grace. Of course, the bullock, irrespective of whether he is owned by a big shot farmer or otherwise, will get the same treatment as his neighbours and it will cost the farmer nothing.

We have heard a great deal about Gaeltacht areas and what is being done. I would ask the Minister to consider the offshore islanders. These are the last outposts of the Irish language. It is all right to let them die out but to kill them for want of medical services would be very unfortunate. I should like to see greater medical facilities being provided for the Aran Islands. While progress has been made, there is still a great deal to be desired. The islands may be cut off from the mainland. Possibly the nurse may not be able to contact her doctor in order to find out how to deal with a patient. We must pay tribute to our currach-men and our lifeboat service who do their best to keep the link open. I wish also to compliment the helicopter service which has saved many lives. While I know the question of telephones is one for another Department, something should be done, whether through a radio telephone system or otherwise, to make contact in the event of a breakdown of communications between the islands. We say what we are going to do for the West but it is only talk.

Would the Minister cut the red tape that is holding up the provision of the geriatric women's unit in Clifden? It is regrettable that people should have to travel 70 or 80 miles to the county home, say, from Clifden to Loughrea instead of allowing them to remain in their own area. An excellent unit is being provided there through the good nuns. The inmates could be visited by their own people, whereas if they are at the far end of the county it is impossible to get to see them.

Reference has been made, although I do not see it in the Estimate, to a mobile squad to deal with road accidents. I should like to know on what basis this will be operated. I have reason to be proud of what is being done in this connection by the Civil Defence unit in our city. I would appeal to the Minister to use our radio and television services for the giving of first-aid lectures. I have the honour of having an all-Ireland medal in first aid, and I know what I am talking about on this. I see the Minister smiling. We beat Mayo, too, at that time. It is very important that every road user should have a smattering of first aid. He never knows but that he might be called upon to use his knowledge for people who are injured in his own car. The Department should utilise our radio and TV services for teaching first aid.

Could the Minister say what has been the effect of fluoridation up to the present? Is the incidence of dental caries showing any reduction or is it too early to say? There has been mention of mouth washes for school children. This is something that should be done the whole year round. When children are away from school at Christmas and during the summer they will be eating sweets and tooth decay is likely to set in. Anything that is worth doing is worth doing well.

When drugs are mentioned one conjures up a picture of long-haired groups lying in the streets. One Dublin Deputy said that going down through O'Connell Street, he could diagnose cases of addiction. It takes a bit of doing for some of the doctors to know whether it is the James's Gate stuff or something else that is responsible for their condition. Something should be done to control the issue of drugs whether by private practitioners or by our dispensaries. They should be issued by instalments. On almost every dresser in the country you find unused drugs and nobody knows what they are for or why they were got. The danger is that these would get into the hands of young children.

There may have been a tightening up in Dublin as regards the availability of drugs but in country areas, now that the Garda are going to be depleted, I can see terrible things happening. I can see these long-haired groups raiding our dispensaries late at night and writing out their own prescriptions. Not alone will our turkeys be stolen at Christmas-time but our drugs will be stolen all the year round if something is not done to keep these drugs under control. There is a great waste of drugs and people should be asked to return them if they are lying about the house unused. This would result in a great saving on our estimates for health.

While we are not fully satisfied with our health service, within the ambit of our purse we are doing a fair job. We shall never please all the people all the time. However, let us hope the Minister will at least carry out the promise of the previous Minister to meet the increased demand in respect of health. Every county is crying out because of the increased demands. There is no denying that and I just add my voice to the other voices here.

Mr. Dowling

I should like to add my voice in praise of the interest which the Minister has in the health services and the efforts he has made to bring those services up to date. We are all aware of the various extensions that have taken place since the Minister took office. We are all aware of his interest in the aged and in those other sections of our community in need of attention.

I should like now to make a very special appeal to the Minister in regard to drug addicts. This scourge has struck the country and, in particular, this capital city. I am aware of the problem because of its existence in my own constituency. A tragic situation is developing. Too many of our young boys and girls are getting hooked. The situation is in need of immediate attention. While certain action has been taken to accumulate information that in itself is not enough. The Department must act without delay, not tomorrow but today, to ensure that the situation is brought under control. Some advice centre must be established to which parents or children can go when children; unfortunately, become addicted to drugs. At the moment parents are running around the city from doctor to doctor, from hospital to hospital, from prison to mental institution, trying to get some information on the treatment of their children. This has been happening for some time. It is a tragic situation. An advice centre must be set up where parents and addicts can get guidance. If advice is not available to these young people they will only continue on this dreadful course, a course which will shorten their lives. One has only to meet the parents of children who have become addicted to appreciate the distress that drug addiction can cause. I know the tragedy. I have seen these addicts. That is why I make a special plea here today to the Minister.

We all know that dispensaries and chemists' shops have been broken into by drug addicts in order to obtain drugs. These addicts are sick people. They need sympathy and understanding. They need attention. Some end up in prison and some go from prison to mental hospitals. I know one young person now in Dundrum Mental Hospital, transferred to there from a city prison. It is a tragic situation. Most of us are aware of the effects of drug withdrawal when addicts become unhinged. The sooner a clinic is established the better it will be, a clinic at which drug addicts can be treated before they reach the point of requiring institutional treatment in mental hospitals or, perhaps, incarceration in them.

I am aware of the drug parties in this city: so are our medical people and so are the police. These are the parties to which young people go in search of a boost. These people must have advice and guidance and it is up to us to ensure that a centre is available for such guidance and advice. In many cases isolation is necessary during the withdrawal period. This is accepted by both parents and by the patients themselves. It is necessary to ensure that drugs are not made available to these patients by visitors. There have been unfortunate cases in which parents have not been able to get their children into institutions or have them kept in institutions during the withdrawal and treatment period.

The Minister and his Department must act, and act now. Tomorrow will be too late. If the situation is not controlled there will be more raids on dispensaries and chemists' shops. I appeal to the Minister to ensure without delay that an advice centre is made available. I am sure that can be done, and done quickly. We must do everything to ensure there will be no increase in the number of addicts and that those who are already addicted have treatment made available to them. Many young people are reluctant to seek the advice of their parents, but they would go to a clinic for help and assistance if such a clinic were available to them. I trust the Minister will take heed of this desperate situation. I speak from experience. I am aware of the scourge.

Another matter in which I have a great interest is the care of the aged. I suggest that the question of short-stay patients in hospitals be examined as well as the development of units on the lines of those in St. Mary's where patients are taken in for a period of six weeks, get the necessary treatment and are allowed home. It means that they no longer become long-staying patients, as in the past. Patients suspected of declining to a condition where they need long-stay treatment are taken in for six weeks, allowed out for six weeks and are taken back again. This has worked very successfully in St. Mary's. There has been a very substantial turnover in aged people. In addition, it has relieved homes where the family though only too anxious to assist and to maintain the aged person, reach a crisis point by reason of an additional birth in the home or a holiday problem or a sickness problem or one of the other problems that one meets with in everyday life. During this period of crisis and tension in the home, one can get the patient into one of these units, if they are available — and they are available in St. Mary's.

I suggest an extension of this type of unit for short-stay patients where they are in and out and, once it is respected by all, we can then have a very substantial number of people getting the treatment that is necessary in order to ensure that they can be maintained in their home for a fairly reasonable period without having to go back into hospital. We now have experience of this in operation. It has been a very excellent asset to this particular hospital. I am a member of the visiting committee there. I am aware of the situation there. It would do other health authorities or the Department, or other hospitals, well to visit this hospital to see the operation of this very exceptional addition that has been installed there. I should like to pay very special tribute to Dr. Godfrey and to the staff of St. Mary's for the development of this centre and for the efficiency of its operation which, I am sure, has brought satisfaction to very many people and to very many homes in this city.

The care of the aged requires very special attention in many other ways. We are aware of the nursing scarcity and of the scarcity of accommodation in many cases for geriatrics. Some time ago, I had occasion to visit the United States. I saw there a very excellent system in operation which was brought into being of necessity because of the nursing scarcity and the scarcity of doctors. They have special units which are made available to personnel who are willing to operate on perimeter areas of a city and to cater for about 20 or 30 patients. These patients are sent to this prefabricated unit — the type of patient that is manageable and that is suitable to the nursing requirements in the area. They get two or three nurses and nursing aides to look after this group of people. There are small overheads. They are sent from the hospital because the doctors know the capacity of the nursing staff in the area. They are convenient to their relatives. In that way, there is the development of a local interest among a large group of old people who otherwise would be taking up bed space in hospital and who would require possibly a greater ratio of nursing staff. If the patient becomes ill or deteriorates, they ring up the hospital and an ambulance is sent to take the patient into hospital and another bed becomes available in the unit.

This has worked very effectively. It has reduced the demand for nursing staff. It has got over the scarcity of nursing staff for geriatrics. It is something that possibly the Department or the health authorities could examine to see if it could be developed here. It works very effectively there. They have all the aids. They have duplicate records so that when the doctor visits, once a week, he is aware, beforehand, of the condition of the patients and of the capacity of the staff to deal with them. Because of the type of patient sent there, there is no real problem and it eliminates the cause of the scarcity problem that is sometimes a factor in geriatric nursing.

I should like to say a word, also, about the very excellent voluntary organisations that are doing so much for the old people in this city and in the country as a whole. Many speakers have expressed their appreciation of the wonderful efforts made by the various voluntary organisations — meals on wheels, home helps and so on. The laundry service, in some cases provided by local organisations, is a great asset in the problem of care of the aged. One cannot speak too highly of the wonderful work of the Sisters of Charity who operate most of these centres in this city. Many people, who would otherwise be hungry because of lack of attention or because of inaccessibility to many people, are now assured of a hot meal, where hot meals are necessary. A large number of men and women devote their spare time or curtail their lunch hour break somewhat in order to bring some of those meals to old people.

The development of the laundry service, as in the centre at Crumlin, is very desirable and means that many more people are reached in the home. The big problem in relation to care of the aged in the home is the question of soiled linen. We have a service in the city where the linen is changed every day or two. Families who can maintain the aged at home but are unable to provide linen are now provided with the linen and thus many more of our aged can stay at home. Unfortunately, the cost of this operation, the cost of the provision of home help, of meals on wheels, of the laundry service and of other essential services that are keeping so many aged people in their homes, falls entirely on the ratepayers of this city.

This is a social problem and a welfare problem and it is one which the ratepayers must pay for in full. I feel that the cost of this service should not fall on the ratepayers of this city. The service provided represents a saving to the Department of Health and to the health authority by reason of the maintenance of the aged in their homes. It should be possible to call upon industry to assist in the maintenance of this service. These are old people who have given most of their lives to building up the many industries and factories in this city and they now find themselves in need of assistance. They made very many people in this city wealthy. If the contribution which the employer makes on the social welfare card were increased, then industry would foot the bill for some of this cost. The older people are entitled to some assistance now from industry which they built up over the years. This is a convenient way to get income. There is no administrative cost involved and the contribution made by the employer by way of stamps for each worker would be a very convenient way of making more funds available for this very deserving social welfare service which should not be a charge on ratepayers.

I am sure that workers as a whole who are making social welfare contributions would gladly pay an extra twopence or threepence in order to ensure the development and extension of this service, as would the employers. I would ask the Minister to consider this additional contribution so that we could develop this very excellent service.

I hope the Bill which the Minister intends to bring before the House shortly will tidy up any of the problems that have been overlooked in the past. The Minister has done a very excellent job with the finance at his disposal. I am sure that if the Minister gives the same attention to the new measure which he has given to the matters raised by Members of the Oireachtas and of the health authorities from time to time for his consideration, accepting as he has done schemes which he considered reasonable and essential, it will be one to which we can look forward as providing complete satisfaction to the country as a whole.

Mr. S. Collins

There is a tremendous atmosphere of non-contention and a desire to progress when we come to a debate on an issue such as health on which fundamentally we all hold the same belief that the quicker we improve the services in every direction the better it will be for everybody. However, I find this debate slightly unreal when on the one hand one considers the desire for advancement and more useful expenditure and on the other, the sinister call for restraint, the warning that we are heading for economic chaos unless certain effective restraints are adopted. This brings us to the big problem, that behind our entire health services there is need for a tremendous amount of re-thinking. Whatever new method of financing the services may be evolved there is no doubt that the present system has many glaring defects which are causing unnecessary hardship, and indeed, unnecessary duplication and wasteful expenditure in regard to administration.

From time to time we hear about isolated cases where red tape has prevented what should be a normal reciprocal arrangement between health authorities. This has occurred in relation to such fundamental matters as ambulance services, where because one ambulance may be 30 yards from a home within a different health area you have to send miles for another ambulance. These may be separate and isolated instances but they point clearly to the fact that the conception of health services will have to be not so much regional as centrally controlled, which will be viable, inter-changeable and effective in serving the people, which is the fundamental purpose of the health service. I know that the Minister shares a very sincere desire with this House to ensure that the best value will be given under the health services for the money available. As we have to re-think in regard to costings on a broader national basis in regard to services that will be inter-changeable, in regard to hospitalisation, ambulance services and certain types of psychiatric clinics for various extern services, we must think not so much on the basis of individual county council areas but how these units can be most effectively used nationally to give the maximum return.

I am saying this because I believe we can evolve a much more effective way of financing the health services and that we can do it quickly if we get down to the job. There is no point in asking the Minister, as I will ask him before I finish, to pay attention to specific matters without trying to make some constructive proposals which will ease his burden.

As the Minister is well aware, my Party is fundamentally pledged to a type of insurance development, a contribution towards health outside certain brackets, that will relieve the direct impact on the taxpayer. One of the things that are very difficult to get over under the present health services is that people who are making substantial contributions are themselves excluded from any benefit under the Act because of their income group. It is well known to all that the very large impact on our rates is borne very substantially by people who can get no effective return themselves from the health scheme and that this leads to the type of corrosion and irritation that you get, I think in many ways unreasonably, from the higher income group that they are landed with the bill and getting nothing from it.

I fundamentally believe that everybody in this country who cannot afford it is entitled to get from us and to expect from us the very best possible available in health service for him but I also fundamentally believe that the person who can afford to make a contribution should make it and should also get in return for that contribution, scaled up whether it is big or small, the same effective type of service. Until we can get that type of health service working we will not get the co-operation nor, indeed, the effective money flow that we need because none of us in public life can deny that we have experienced over the years repeated appeals from people to get health charges reduced, to get hospital bills eliminated or to get various types of reductions for people who could not meet, despite their income, the severe impact that the incidence of high recovery costs imposes on families, where hospitalisation periods are long and where diseases are lingering.

I feel we should in a completely noncontroversial way come into this arena of discussion and pool our resources mental and technical and our capacity to work out solutions in a unified way for the purpose of getting the basis of this whole health finance right because it is something that should not be in the arena of politics.

Mr. O'Hara

Hear, hear.

Mr. S. Collins

It is something that it is our bounden duty as a Parliament to expedite in its effectiveness as quickly as possible because there is no greater truism than that while we are fiddling or neglecting or delaying things here people are literally dying because of services that should be available and are not.

As I said, this debate becomes unreal when it is overshadowed by the grim devastating warning of chaos given to us the other evening by the Minister for Finance and while I am going to talk of things I would like to see done I feel I am doing it in an unreal situation knowing that there is a hole in the bucket and that the money is not there. I will not enter into acrimony on the health discussion to suggest that there had been violent squandermania in many directions where the return was nil and that at least we would not be complaining if there had been further expenditure in health if it had been effective and useful to the community as a whole.

I believe, knowing as I do over a long number of years the present occupant of this office, that he is groping with enthusiasm for some efforts, realistic ones, to be made to give him the opportunity of knowing that he can go ahead with paced improvement, paced development, in bringing the health services into effective benefit for all sections of the community. That is why I am not afraid to say that I rejoice in the fact that very substantial improvements have been made in the field of endeavour where neglect for years had been the hallmark. I am not churlish enough not to say fairly and squarely that particularly with regard to mental disease and mentally retarded children there is a new awareness abroad, a new consciousness of responsibility and a great impetus to development in that type of treatment which was once a furtive, secretive, unacknowledged disease, particularly in rural areas, and that we have been able to gradually, and I hope we will more effectively in the time to come, make people realise that in the main mental disease is no more unmanageable than ordinary physical disease and that it is a disease that in the main can react to treatment and can be treated. I hope we will be able to deal with mental disease in this country in the not too distant future with the same effective results that we have in the last 20 years been able to effect in the field of tuberculosis.

The greatest enemy we have had to that development was furtiveness and ignorance. I want the Minister and the Health Department and the health authorities all over this country to keep pushing and plugging because a lot of the morbidity, moroseness and psychosis that develops in this country could be arrested at the beginning if ignorance was dissipated and the simple realisation inculcated into the people that these difficulties can be dealt with effectively on a medical basis. It was always something that rankled deeply within me that we had this wall of difficulty, diffidence and ignorance. I have no hesitation in saying that in the last few years an effective drive has been successfully initiated to get rid of all the unpleasant background to this matter, the anxiety to hide and deny. We do know the neglect that families used to hold out to members who were, as they used to say in Irish, "Beagánín le craobhacha". I want to say that as far as I am concerned there will never be any question from me regarding the expenditure of money that will effectively add impetus to this good work.

As I said initially, and particularly in this field of endeavour, we will have to carve up our national field in the most effective way with the use of the personnel and the units at our disposal. We cannot allow the niceties of red tape or the delineation of county boundaries to disrupt a general service. We know that we suffer from a severe limitation in the number of trained personnel available for this service. We know that psychiatrists are not easy to get; we know that their training to deal with modern problems is a long and difficult one and that their availability at our capacity to pay them is limited. I think that we as a community will have to face the reality of what the cost of these people is going to be and because of that we should sit back in a deliberative and noncontentious way and bend all our efforts to discover an equitable method of financing our health services so as to take them out of the arena of party politics and so give us a chance to look after and cherish all our people equally.

I started with a commendation to the Minister, his Department and the health authorities for the advances that have been made in dealing with what was a very black spot in our general health difficulties. We are all delighted at the great impetus and strength of purpose building up behind the campaign to look after the aged. There is nobody more aware than I am of how complex the problem is, of how difficult it can be. It is a problem which can be tremendously difficult where it should not be difficult at all. Where people have become reasonably affluent and are beginning to enjoy higher standards of life, the old people become a nuisance and a problem to them, much more so than when they were less affluent. That is why there is such a field of loneliness for old people and neglect of them which we are going to find it very difficult to tackle.

It is an undoubted fact that in the big family circles in the lower-income groups you will find a lot more affection in a communal way for the aged members of the family. I have experienced that in an on-the-spot investigation of circumstances. While it may be helpful to institutionalise some of these people and to hospitalise them from time to time to deal with certain ailments, fundamentally the problem in the care of the aged goes back to our capacity to keep them in their home environment in reasonable comfort. At the end of their days it is in the family circle, among their grandchildren and, perhaps, greatgrand-children, that the old folk will be happiest.

However, we must come back to the problem that all this costs money. The people to whom we entrust this home service and care, the guidance and help needed for a family caring and protecting its old folk costs money and costs money on the basis that the modern trend is for these costs to rise higher and higher year after year. We have to face this problem on the basis of rising costs and there is no use complaining to the Minister if we cannot find an equitable and reasonable method of finance. The guidelines are sound, the way of development is clear and I believe that a proper approach to the problem will find the response of the people enthusiastic and full.

As long as we can evolve a health scheme the cost of which can be borne on a reasonable basis by those who are able to bear it and who also get a proper return for it, I do not think we will be denied the money. The Minister will have to come to grips with the problem of the contribution that will have to be made directly by people who can afford to contribute and the return that must be given to them, on a non-mendicant basis, for their subscription to the maintenance of the national scheme. One of the things that stick in my gullet is that we still have, not in the old horrible way, but in the lingering nausea of tradition, a mendicity, a beggary, in health that does not become us as a people and does nothing for our self-respect as a nation.

I know Deputy Dowling is very sincere and apprehensive in connection with the question of drugs and the use of drugs by young people in the city and in his desire to see control. I realise that there is no greater incipiency for growth than there can be in the use of drugs. The Minister would be better to keep the matter under active review than to allow people to blow up the problem into something that would cause further investigation by youth. I am sure that the Minister in co-operation with the Department of Justice and the police is keeping the situation under active and firm review but I do feel that there are difficulties that have to be faced up to immediately in connection with the question of control. The distribution of drugs through the dispensary system is leading to serious abuses in a most innocent way. In the country, you find people swapping pills to see if Mary's pills will do Katie any good and Katie gives Mary some of her pills to see if they will do her any good. The people become home doctors.

The time has come when the Minister's Department, pharmacists, dispensary doctors and everybody else must get together to work out as nearly a foolproof a scheme of distribution as possible. If they come together on the problem, if there is an arrangement whereby, where possible and convenient, the pharmacist will be brought into the scheme of distribution, there can be more control and more positive knowledge as to distribution.

We have to face the fact that with the tremendous growth of antibotics and drugs for all diseases the cost item is becoming staggering. Efficacious as these modern drugs may be, they must be distributed with great care because, apart from the dangers that may ensue from misuse, the cost is great. None of us will deny the right of user but we all expect that the drugs will be used to the fullest extent for the benefit of the health services rather than with any profligate disregard for cost.

One knows that there is a wastage all the time because of the tendency where people get things for nothing to be profligate or careless in use. There is a broad avenue of development. A wide area of effective control will ensure savings in cost in that direction or, even if it does not ensure savings in cost, will ensure that money will be preserved and diverted to the procurement of other and expensive rare drugs for special cases. Again, I want to see this done, not in the spirit of skimping or saving at the expense of patients but on the basis of ensuring that the guiding axiom and principle of the whole system of financing the scheme will be to give better value to the people of Ireland for the money that is spent.

We may have criticisms of the Government and of their policy and there are wide fields of squandermania that we will be dealing with next week when we can hammer the Government on their general policy, but in regard to health there should be one communal and united ambition to give of our very best to that section of the community that most needs our help. The person who is physically or mentally ill, who is suffering from senility or from all the problems involved in growing old, deserves the very best help and sponsorship of this House. But again I come back to the fundamental ulcer in the whole health system, which is the fact that vast sections of the community think that they are paying a very big contribution and getting no return.

I was glad to hear young Deputy O'Leary pay tribute to the Voluntary Health Insurance Scheme and suggesting to the Minister there were avenues of development of the scheme that he might well consider. It has been in many ways a remarkable success. Many a case of what would have been real hardship has been prevented by the fact that that body is in existence and that more people are beginning to use it. We know that the wider the benefit and the greater the intake of membership, the greater the risk of demands being made on its resources, but also the greater the premium income. Therefore, with very little subvention to help them they should be able to develop and reach a much wider market in the insurable ranks in the country. They have done a good job. The setback they had last year is, I am sure, due only to the fact that they grew a little bit too fast; but co-ordinated, planned development here would be a great help to the community at large and a substantial relief to the Exchequer.

There is substantial merit in a scheme for people who have the capacity to pay the contributions, whether it is a mere 1/6d or 2/- or 4/-or 5/-. Over the years this Dáil has failed to find what is, from the national point of view, an equitable way of paying for the services we must give our people.

The Minister must be weary of repetition here and of everybody riding his own particular hobbyhorse. I have examined carefully the proposal about future developments in hospitalisation, the availability of medical training centres and the desirability of getting a centre where the highest standard of medicine can be made available to our people. However, when the Department is considering the siting of hospitals, they must remember that the real basis must be the need of the people. There will be the occasional case that will need the ultimate in skill, up-to-date knowledge and everything else, but there is a tremendous range of specialist and surgical treatment that can be given nearer home. We must, once and for all, stop thinking that there is no medical capacity in Ireland except in Dublin.

I nearly rose up in flames when the suggestion was made that the hospital we fought for, which so many generations of Deputies before me in this House fought for and whose foundation stone I saw being laid, should be done away with. It is giving a service to a far-flung peninsular area with islands around it. Be very slow to put your hands to the destruction of a place like that or to curtail its effectiveness for the purposes of centralisation. It is giving a service the people down there appreciate. It is staffed within its limits with the most competent of people, and the 100-odd miles from Allihies to Cork or the 90-odd miles from Muintir Mhara to Cork was the death knell of many before we had this hospital. I can think of the fight that was made by people who were a credit to this House, most of them now dead, and I give a pledge to those people that, as long as I remain in public life and represent the people of South West Cork, they will close Bantry hospital over my dead body. That is the only controversy I am putting into this discussion, but I would be dishonest if I did not tell the Minister what I believe on this question. I told it to him before and the Minister, with that roguish twinkle in his eye, knows perfectly well that it will not be as easy to deal with a problem like that as it seems in a written report. I am quite sure he will give it the consideration it deserves and will meet all the people down there when the problem does arise if he is still the incumbent of this office.

I do not intend to delay the House indefinitely. In regard to health generally, we may not have got to the very highest standard — in fact we know we have not—but we are making progress. We can make more progress if we come into this House and honestly try to deliberate in a non-contentious way on real needs and get our priorities right. The advance made in the last 20 years has been in the nature of a social revolution. Our awareness of the necessity to finance this type of development is becoming keener and our capacity to do so is becoming greater. It is in that spirit that I say to the Minister: Leanadh sé leis an obair agus rath Dé air.

Mr. Andrews

I shall be brief on this very important Estimate. I shall not be contentious because that is not my form. I shall deal first of all with problems in my own constituency of Dún Laoghaire-Rathdown and then with health problems in general. At the moment there are women in my constituency, in Sallynoggin and elsewhere, who are holders of medical cards. They are mothers and some of them have very large families. They are not in receipt of social welfare benefits. Their husbands are because they contribute to the various schemes. These mothers cannot avail of the major dental services in the area because they are not in receipt of social welfare benefits. These mothers, therefore, are compelled to travel into Dublin to the Dental Hospital. The Dental Hospital, as we know, is situated at the back of Leinster House. There is a long waiting list and these mothers, because of that long waiting list, are put to considerable inconvenience. I have known one case in which a mother of a fairly large family was told she could not get treatment for a couple of weeks and then she had to wait a considerable part of the day.

I am not now being critical of the Dental Hospital. I should like to make that very clear. Those who run the hospital are subject to a system — I think it is an unfair system — in the context of that about which I am speaking. I would be the last person to be critical of the Dublin Health Authority. It is a most efficient authority. I have always found the authority most courteous on any occasion on which I have approached it on behalf of my constituents with particular problems.

To come back to the medical card holders who are not in receipt of social welfare, they are not in receipt of social welfare because it is a contributory scheme. There are exceptions. The pregnant or nursing mother will receive major dental treatment and, indeed, conservative dental treatment as well. But these are the exceptions to the general rule. If the Minister would bring this problem to the attention of the Dublin Health Authority it would do a great deal of good. It would save these people who are, in the main, in the lower income group who, at the moment, because of the inaccessibility of the local dentist, have to spend days possibly away from their families, to say nothing of having to spend money they can ill afford on bus fares. The scheme disrupts the home to some extent. I would ask the Minister to consider this problem.

I have been told that the cost of major dental treatment in Dún Laoghaire would be £15. The actual expenditure in the circumstances I have outlined is £37. This seems extraordinary. The system would be much more efficient if the suggestion I make were accepted by the Dublin Health Authority. It would also make the position easier for the people concerned. I know the people in the Dublin Health Authority are reasonable. I hope they will examine my proposition and implement my suggestion without delay.

The Minister referred to the hospitals re-organisation. We have a number of private hospitals in the constituency which I represent and, before the Minister starts re-organising the system, I would ask him to consult with the hospitals in Dún Laoghaire-Rathdown. The Minister has said he will do so. I have no doubt he will. It is very important that the people affected should be consulted before any changes are made. Decision should not be imposed from the top. It should come from the bottom up in consultation with those involved. The Minister has undertaken to consult. I believe he will do so.

It is only right that we should pay tribute to the staff of St. Michael's Hospital. They are doing a magnificent job, not only for the people of Dún Laoghaire but for people from outside the area also. This is one of the hospitals which would be affected by reorganisation of the system in the city and county. I ask the Minister to pay specific attention to any views put forward by those concerned in the running of this hospital.

With regard to the mentally ill and the mentally handicapped, we have in recent times become aware of our responsibilties to these people. I think it was two years ago I mentioned the question of a test immediately after or even before the birth of the baby. I congratulate the Minister on introducing these tests. We now have the test for phenylketonuria. This is preventive medicine and the idea is first class. The Minister has told us that 37 people have been saved from becoming mentally ill. It is to the credit of the Minister and those who introduced and operate this test that these people will become normal citizens, capable of taking their places in normal day-to-day life.

It is very easy when one is not directly concerned to look on the mentally handicapped or the mentally retarded as sent by God for some specific divine purpose, but I am very glad that the time has now come when people no longer hide their handicapped children from the gaze of the neighbours. It is most important that they integrate in our society and are brought up to a standard, as far as possible, so that they become part of our everyday life. This is the general trend nowadays. I do not know whether "misfortune" is the correct word to use in relation to these children. Sometimes one might say it is a cross to bear, and so on; I am not competent to comment. I believe that the parents of these children should be given every assistance—in other words, these children should be made a State charge irrespective of the family financial background. I believe the people of Ireland would have no hesitation in paying whatever increased taxes would be necessary to implement my suggestion in relation to the mentally ill and the handicapped generally.

Mr. O'Hara

Hear, hear.

Mr. Andrews

Since becoming a public representative, I am even more aware than before of this problem in my constituency and, indeed, in the country generally. Many people, because of their wealth, would not avail of the service I suggest, and which I believe all fair-minded people would agree to, but we must remember, also, the people who are left in the wilderness — the middle income group and the lower income group. We hear about people living in suburbia, having their own car, and so on, with an income of £2,000 a year. Nowadays, it is difficult enough to live in suburbia and to run a car on £2,000 a year when one considers the mortgage repayments on a house and the hire purchase repayments on the car, which is no longer a luxury but a necessity, and other repayments and incidental expenses. That is one reason why I urge that the mentally ill and the handicapped generally be made a State charge, regardless. It may not be a popular thing to say or to do but that does not interest me. I am not in public life to make popular statements but to express a point of view, independently, if needs be. In addition to the middle income group, the lower income group also would benefit from my suggestion in respect of the mentally ill and handicapped people generally. It is very important that the Minister consider this matter and, by advertisement or otherwise, foster the view that, if at all possible, our mentally ill and our handicapped in particular should not be institutionalised but rather should be kept at home where at all possible. The money spent on keeping such a child or such a person in an institution could be spent to better advantage on bringing up that child or on keeping that person in the home environment.

I have written to the Minister about a case which exists in Dún Laoghaire-Rathdown. It concerns a totally handicapped child who is supported by a spinal brace down along where his spine should be. He is sleeping on a chair in the front diningroom of his widowed mother's house and has received very little assistance from the State in the context of the home environment. I have been pressing and shall continue to press for the building of an extra room to his mother's house for him. This child is living among 11 other people. Any necessary expense should be undertaken in that case. It is a matter of urgency, as the Minister appreciates. I strongly urge that the Department of Health and the local authority build a room forthwith for this 16 years old boy who is severely handicapped.

From time to time, I have spoken in this House about paraplegics and I shall continue to do so as long as I consider that something still requires to be done for them. Under the 1967 Finance Act, the then Minister for Finance gave a free car tax allowance to paraplegics. This represented a first-class advance in terms of a social conscience. It is to the credit of the Minister for Health that he has urged local authorities to make allowances to paraplegics in the same context. It would be useful to examine the question of giving a far greater tax-free allowance to paraplegics who, if they were in State institutions, would cost the community a great deal more money. These people should be encouraged to work full-time or part-time and I urge that their earnings be not taxed.

There has been much talk about rates and, indeed, this subject is aired every year. I regard rates as a penal tax. There have been so many suggestions advanced in relation to the rating system in general that I feel I have no further point of view to offer except to say, as the Minister said, we have to pay taxes no matter whether it is locally or to the Exchequer, and it is less painful to have tax charged from the Central Fund rather than from local rating. If one receives a rates bill for £100 or £120 and can ill afford to pay it, it is a pretty painful way of having taxes extracted. However, this subject has been talked about and beaten to death and nothing has been done about it; there has been absolutely no improvement in the situation as far as I can see. One of the main complaints made to suburban Deputies is "What are they going to do about the rates?" I reply that there has been a lot of discussion about the matter. It is very difficult to give the people who ask the question a proper answer.

In regard to the aged much has been done. The Minister spoke about the marvellous work being done in Kilkenny and I should like to mention a number of organisations in my own constituency which is one of the most socially-conscious constituencies in the country. We have a number of first-class organisations doing voluntary work on behalf of old people in the area. We have the Sallynoggin Old Folks Association, Meals-on-Wheels, the Dún Laoghaire Old Folks Association and the Society of St. Vincent de Paul, as well as the home help people. I often feel in regard to these organisations that there is not enough co-ordination between them. They are all doing the same very worthy job but it is a pity they could not come together and do the same job better and more efficiently. This is not to suggest that they are inefficient, because they are not, but if there could be more co-ordination in the dispensation of good it would be better from the point of view of the recipients, possibly in terms of more help. In Dún Laoghaire we have the largest number of people living on their own. The work being done for these people is first-class. In Glasthule we have a complete local authority scheme given over to the care of the aged with a full-time social worker employed to look after these people. To her credit, and to the credit of the environment in which they are, these people are extremely happy. One of the flats is given over to what you might call a mini-community centre. It is really a first-class operation of its kind. The Minister is well aware of this scheme and has given much assistance to this type of development. We in Dún Laoghaire are very grateful to him.

On the question of social workers I have already brought to the attention of the House by way of Parliamentary Questions and otherwise the great lack of emphasis on the part of the Department on these workers. The department of social science in UCD turn out many graduates who have obtained a social science degree and to my knowledge quite a number of these graduates have to emigrate. Quite a number of them have gone to the Six Counties while others have been going to England. It is a pity that they are not kept at home. There has been great emphasis laid on psychiatry and on social work generally, and rightly so, in the Minister's statement, but it is a pity that these social science graduates are not encouraged to remain in the country.

Mr. Dillon

What do they know when they have their degree?

Mr. Andrews

I would imagine that they would be far more qualified in terms of psychiatry and so on.

Mr. Dillon

No, they do not do psychiatry, they do psychology.

Mr. Andrews

Well, psychiatry or psychology. There is a suggestion that they should spend a further year after obtaining their diploma in social science studying psychiatry.

Mr. Dillon

I am distinguishing between psychology and psychiatry.

Mr. Andrews

I know. There is so much emphasis on the sciences now, the importance of psychiatry and psychology, that the more trained people we can have the better from the point of view of people who receive these services.

Mr. Dillon

I can only invite the Deputy to study the value of the social science degree not only from our own universities but from other universities. It is not an academic discipline at all.

Mr. Andrews

Well, it is a discipline.

Mr. Dillon

I do not think it is a discipline but you can believe anything you like.

Mr. Andrews

I regard it as a fair discipline but the Deputy takes the opposite view and I suppose we can agree to differ. I would ask the Minister to encourage the social science department at UCD to encourage these people to remain here as social workers. I should like now to quote the 1966 Report of the Commission of Inquiry into Mental Illness. At page 121, paragraph 168, it states:

The need for social workers and the respective roles of such workers and nurses in community care are discussed in paragraph 76 and 77. The basic qualification for a social worker is a diploma or a degree in social sciences.

This surely lends weight to the point I have already made and about which Deputy Dillon disagrees. It continues:

A psychiatric social worker is a social worker who undertakes a further period of supervised practical training and a course of study in psychology and psychiatry.

This would be the extra year I was speaking about.

The exact training programmes leading to qualification as a psychiatric social worker vary considerably from country to country but generally include —

(a) a period of training — usually one year — in a psychiatric hospital;

(b) a further year in a university during which the academic side of mental health and mental illness is studied; and

(c) a period of supervised training on case work.

This is the important thing, case work. The more you are involved with the people the better. You get your degree and then go into the field and get experience in that way. The paragraph continues:

Variations of this include (1) a training scheme whereby, after training in social studies, the student works in a mental hospital as a trainee under the supervision of an experienced psychiatric social worker....

and so on. This is going on to the psychiatric side. Those are the pleas I would make for social science and I would ask the Minister to consider a scheme to encourage social science graduates to remain in the country for the benefit of the community.

I was studying A Summary of the Health Services, a grand little booklet the Minister has produced. It gives a lot of information but I always feel that Departmental publications could be made more easily readable. I know it is difficult in the field of medicine. Everybody knows tuberculosis is TB but there are other scientific and involved terms that the ordinary layman finds it hard to get his tongue around, never mind understand. The simpler the English used the better; and, if clichés must be used to express a point of view, so long as the person to whom you want to give the knowledge understands it, it does not matter. I am not suggesting that A Summary of the Health Services should be a series of clichés. On the contrary, but it should be made easier to read and to understand.

The Minister during his speech mentioned that a supply of medicines to the middle and higher income groups is available free of charge where it is found there is undue hardship. There are many people, particularly in the middle income group, who find it difficult enough to live and difficult enough to pay their bills for drugs and medicines when they have a large family. It is important that these people should be made aware of the fact that, if they are suffering from undue hardship, these medicines are freely available to them.

I am glad to see that the Minister has extended the infectious diseases allowances to the Borough of Dún Laoghaire.

I should like to make one request to industry. We have been discussing the aged and the question of people retiring. One often wonders is there any young academic around who would do a pamphlet on training for retirement. How little emphasis there is in this country on the idea. A man is in work today, he is 65 tomorrow and therefore he is out of work. This must be a traumatic experience for a man who has worked for 40 years or more.

Mr. Dillon

Not all that traumatic. It is quite agreeable.

Mr. Andrews

There are some people like Deputy Dillon who have a liking for culture, the arts and so on and who find no difficulty in retiring, but there are other people who have not got that facility. There are workmen coming out of work after 40 years and going on to a small pension. I wonder why these men are not trained to retire, trained to know what to do with their spare time, whether they could get a part-time job or be reintegrated into their company at a lower level of that company. In other words, when a person retires he should be kept occupied, given occupational therapy, because the death rate among our retiring senior citizens is quite considerable.

Mr. Dillon

That is hardly surprising, you know. Elderly citizens are prone to die and it is the threshold of an eternity of bliss. Let us not be too pessimistic about this eschatological prospect.

Mr. Andrews

I am not being pessimistic about the whole thing. It will, for example, be a great pity when Deputy Dillon retires. There is no question about it.

Mr. Dillon

That is very kind of the Deputy.

Mr. Andrews

In that sense I think the Deputy could go on for another ten or 20 years.

Mr. Dillon

I agree with the Deputy that it is desirable to train the elderly to find suitable hobbies.

Mr. Andrews

Suitable hobbies or part-time employment. There is not enough emphasis on this. Our larger industries have not been placing enough emphasis on this. I am not being pessimistic about this life or the afterlife.

Dr. O'Connell

What about our Civil Service?

Mr. Andrews

I am not being abrasive about this. I am just making a suggestion.

Mr. Dillon

It has been done in many cases. Men of over 65 have combined in small enterprises and used their mutual skills.

Mr. Andrews

This is the sort of thing I would like to encourage. It is a tragedy to see a man retiring at 65 and becoming inactive. He is active on Friday and inactive on Monday. He does not know what to do with his spare time. If he can earn a few shillings to supplement his pension, all the better; but if this cannot be done at least he should be given some occupational therapy. We have already projected the point of lowering the age for the old age pension from 70 to 65 but this is a matter for the Department of Social Welfare.

The Minister is already aware of a problem in regard to the Sale of Goods Act. Where a manufacturer prepacks goods for a retailer and a health inspector finds something wrong with the prepacked goods it is an extraordinary anachronism that the retailer is responsible for the contents of the defective articles. It is extraordinary that this legislation has not been amended, that some responsibility is not laid at the door of the manufacturer. Judges on many occasions have expressed the view that it seems unfair that a retailer is inspected by a health inspector and if the contents of a prepacked article are found to be defective the retailer is held responsible, not the manufacturer. I would ask the Minister to look at this point.

We have in Stillorgan one of the most modern ambulance services in the country. If ambulance services are to be modernised the country should take a look at the Stillorgan Ambulance Service as a pilot scheme. It is a first-class scheme of its kind and it is doing a magnificent job for the city and county of Dublin. It is most efficient and most modern.

I should like to thank the Minister for receiving the deputations he has met with me and for me from the constituency I represent. It is a marvellous thing to have a Minister who is as accessible as is the present Minister for Health. He has been made well aware of the problems relating to my constituency. He has met quite a number of deputations from the constituency. The Department are at last becoming far more aware of the need for an up-to-date medical health service. They are becoming aware of the needs of the people generally and to them and to the Minister I offer my thanks for the courtesy with which I have always been met.

Mr. O'Hara

This debate has gone on for some considerable time and very many points of view have been expressed by Deputies from rural and city areas. Coming in at this time one feels that there is a danger of repetition but I will try to avoid this as much as possible. I very much appreciate the courtesy, kindness and charity of our Minister for Health, Deputy Seán Flanagan, who is a neighbour of mine and against whom, in the new constituency of East Mayo, I may be contesting the election in the near future. He is a good Minister for Health, charitably disposed, a man who would do anything he could within the limits of the resources of the Department of Health to further the health of our people, not alone in his native county but in any part of the country.

I have had personal and practical experience of the charity of Deputy Seán Flanagan. On one occasion when going home from Dublin I had a breakdown at Strokestown. Deputy Flanagan, who was not then a Minister but who was a member of the opposing Party, came along, diagnosed what was wrong with my car, told me to leave it there and that he would leave me home. He had to do an extra journey of about 50 miles but that did not worry him; he would have done it for any other person left on the road. Deputy Flanagan's ability as a Minister is much appreciated by the people. I would also like to say about his civil servants that they are always sympathetic, co-operative and helpful.

It is true to say that the Minister for Health will be familiar with most of the matters I have to raise here by reason of the fact that he is a Deputy representing the new East Mayo constituency. He goes around the area on his political occasions and is familiar with our problems at first hand. We still have many problems but I must say that I can remember a time in my 25 or 26 years in public life when we had a few hundred TB patients on our waiting list. The first figure I ever heard for that number was 350 odd. Thank God we have none on that waiting list today and the position is that we have too many awaiting beds.

Mr. Dillon

Who did that?

Mr. O'Hara

Deputy Coogan could make that clear. He did it yesterday. He said the inter-Party Government did it.

Mr. Dillon

We were accused of bankrupting the country to do it but we are proud that we did it.

Mr. O'Hara

Successive Ministers have done all they could down through the years to improve the lot of our people in the various fields of health. It has cost the taxpayers and the ratepayers considerable sums of money to do so. However, like other Deputies who have spoken, I think it is my duty to pay tribute in this House to the various voluntary services, to the nursing services, the Jubilee nurses and to the old medical officers who many years ago had to travel on their pushbicycles up the mountainsides. It must be said, too, that as far as they were concerned money did not come into the matter. If families were too poor to pay, in 99 cases out of 100 the treatment was free and many of them, if they had a few shillings to spare, were not slow to put their hands in their pockets and help out. It goes on even today.

The general practitioners in my part of the country, and the Minister is aware of this, do not bother about form filling. They go out and attend to the people and if the people have not the money to pay that is all right. They solve many of the problems that would normally fall to be solved by the health authorities. Many of them are natives of the area; they understand the problems and they do their best to help out in any way they can.

We all know that the expansion of the various medical services in different counties has been difficult, especially in counties such as my own, widely stretched from Shrule to Killala Bay and from Charlestown to Blacksod. As far as Mayo County Council is concerned there has always been a spirit of co-operation to do what is possible to help all sections of the community no matter what political Party was in the majority in the council. We are proud of that fact even if we have the highest rate in the country. We were forward thinking and are proud that with the resources at our disposal we did everything we could to improve the lot of those afflicted in one way or another.

While we would like to get more money and have asked for it in recent times we appreciate the help we have got and would be glad if it could be found possible to further relieve the burden on the rates. We have had to increase our rates by something like 16/- in the £ and that is a very severe burden on our people. In addition many of our patients have to use public transport or hire cars to get treatment and this adds to the cost as well. While the people in the builtup areas have their problems, and I do not want to erect a barrier as between city and country, they have certain advantages when it comes to the question of hospitalisation and specialist treatment.

The people of Mayo avail to a large extent of hospitals in Dublin for the treatment of patients. I have not the figure here as to the cost of that to Mayo. A certain percentage of the expenditure is recoverable from the Central Fund but it still represents a big item to the county. In my 25 years in the local authority I have never heard criticism expressed by a Mayo patient of the treatment received from the doctors, nurses, or anybody else in these hospitals. These people have to travel from Belmullet or Foxford or some remote rural area and are not familiar with the city. When they come to Dublin they are treated as princes. Any kindness that can be afforded to them is forthcoming. The people I represent have been loud in their praise of the treatment they receive. These people are mainly medical card holders. I feel that it is my duty to express here on their behalf the tributes they have paid to the Dublin hospitals.

Patients who are sent to Dublin are issued with travelling vouchers which in turn cost money. Many of them are long term patients in institutions for the treatment of cancer, such as St. Luke's Hospital or St. Anne's Hospital, where treatment is expensive. Regardless of cost, our people in the county council at local level have always ensured as far as possible that the service is provided.

If it is possible to be more generous to counties like Mayo that should be done. It is only fair that special treatment should be afforded to Mayo County Council. Added to the cost of running our own institutions and paying for treatment in Dublin is the increase in the cost of foodstuffs, medicines, salaries and other items. These increased costs create a serious problem. It seems to me that we have not yet reached the limits. The turnover tax had the direct effect of increasing our rates by 2s 6d or 3s in the £, not to mention the demand for increased wages consequent on that tax in order to compensate workers for the extra costs involved to them. This is a burden we have had to bear. As time goes on the load is becoming heavier. Now there are increases in loan charges. In order to finance projects under the local health authority we have, at least in the short term, to borrow money in order to get the work under way. As everybody knows it is difficult, almost impossible, for local authorities to borrow money and it will become increasingly difficult because, as the Minister for Finance has told us, there is a general scarcity of money. That also will have the effect of increasing rates. Where will it all end? All we can do is hope for the best.

Mr. Dillon

Or change the Government.

Mr. O'Hara

The people will be afforded an opportunity in the near future of doing that and we know we can rely on them to act intelligently, as they did in the referendum.

The proposed Health Bill has been referred to. I know I am not at liberty to discuss anything that is not before the House but I think I am entitled to refer to the Health Act. I know something about it. I remember the debate in the House when it was going through. I remember the manner in which it was dealt with in this House. I was not impressed, to put it mildly, by the way it was handled. I felt then that it was a slapdash measure that was being piloted through the House by a gentleman who, with all due respect to him, did not seem fully to understand the contents of the Bill. I was here and watched the whole thing.

An Ceann Comhairle

The Deputy will appreciate that it is not in order to discuss legislation on the Estimate.

Mr. O'Hara

I think I am entitled to make this comment.

An Ceann Comhairle

The Chair has another viewpoint. He thinks the Deputy has no right to discuss legislation on the Estimate.

Mr. O'Hara

The many defects in the Health Bill which went through this House were responsible for the fact that Mayo in the present year faces an estimate for health alone of roughly 48/- in the £. I would submit that there is need for a general overhaul. There is a good deal of overlapping. I sincerely hope that the Bill which the Minister proposes to introduce will be a different type of Bill from that which was passed many years ago.

An Ceann Comhairle

We cannot discuss Bills in this fashion. The House will get an opportunity of discussing the new Health Bill. We cannot anticipate the debate on that Bill. The Deputy will get every opportunity when the Bill comes before us.

Mr. O'Hara

There is the matter of delay in admitting patients to our local hospital. We are fortunate to have the good county hospital in Castlebar which was built many years ago. There is a limited bed capacity. By reason of the change in trends as a result of which many more people are availing of hospital treatment, there are delays in admitting patients to the county hospital, particularly at certain periods of the year. We have a very good surgeon and assistant surgeon and I should also like to pay tribute to the matron and nursing staff for the great work they do but their work is being undermined and they feel frustrated because of the long waiting list for admittance. There is difficulty involved in sorting out the patients who need urgent treatment, an operation or some other attention. It is difficult work and the time of the matron is occupied in trying to make decisions as between patient A and patient B. The Minister is present now and, being a Deputy from Mayo as well as being Minister for Health, I am sure he is approached, as I am from time to time, about certain cases: for instance, the case of a working man who has suffered a slight injury and is awaiting a minor operation. He may not be able to go to work in order to earn money for himself, his wife and children. The income of the family suffers accordingly. Therefore, it is necessary that further extensions be made to the surgical hospital at Castlebar.

Some time ago a new maternity wing was added to the hospital. I have not observed this myself but I have been told by members of the engineering staff that there is a serious fault in the construction of that section of the hospital. The fault relates to the sewage disposal system. This could be a serious health hazard if something is not done urgently. I cannot understand how these architects, engineers and clerks of works can turn out faulty jobs such as this.

As a member of the visiting committee of the County Mental Hospital, I visited the hospital last Tuesday where we had a meeting. As a result of rumours which were floating around we decided to carry out an inspection of the new admission unit to the mental hospital. We had no engineers on the visiting committee. We were, if you like, all lay people, but we could not help observing that there was defective work carried out in that new admission unit which, I understand, was due to be opened officially by the Minister for Health some time ago. In all probability, for the reason that there are, perhaps, some proceedings pending or that some action is being taken about it, the institution has not so far been opened.

We came away from that inspection on Tuesday last a very disappointed group to think that the Irish taxpayers and local ratepayers have to foot the bill for such an institution, to think that some architects, contractors or other people along the line fell down on the job to such an extent that there is dampness on the walls and materials were used which were unsuitable for the purpose, thus producing defective work. I hope when the Minister is replying he will be in a position to comment on this, as it is not the only occasion on which certain people who want to get rich quick have tried the easy way out. I cannot understand how the architects, clerks of works and other officials who supervised this work did not observe these faults before we were stung financially. It is not only a question of finance; it is also a question of the use and benefit this building would be if it were in proper shape for patients to be admitted to it.

It is time for the Minister or whoever is responsible to run these people to earth, to see they will not get away with turning out shoddy work. Whether it means a sworn inquiry or bringing them to the High Court or to the Supreme Court, it should be done rather than let them away with it. My information from the county manager is that only a very small sum of money is now due to the contractor who carried out this work. It may be that difficulties will arise in having things straightened out to the satisfaction of all. I doubt very much if it can now be straightened out having regard to the shoddy work I have seen, and I claim no special technical knowledge, nor do the other members of the committee who visited that hospital with me on Tuesday evening last. I would appeal to the Minister to take all the necessary steps to see that this dampness is eradicated. The floors, which have been laid by the South of Ireland Asphalt Company, who do this kind of work all over the country, have started to lift, and it must be obvious to anybody that there is some dampness or some other serious fault somewhere.

We have made good progress as regards the mental health of our patients in Mayo. Some years ago we had around 1,200 patients, many of them long-term patients. We inherited what might be called a great problem of old chronic patients who had not available to them the benefit of modern drugs to relieve them of their illness. We still have some of them with us but, as I say, we have made progress and the figure is now under 1,000 — 978 or 988 was the most recent figure I heard — and it is true to say that if some of these could be taken and cared for by their relatives that would further relieve the problem. I have actually had that from the RMS; if these people could be cared for in suitable circumstances by relatives their health would actually improve.

Our doctors visit various clinics all over the county — Belmullet, Ballina, Swinford, Ballyhaunis and elsewhere — to meet patients who are not seriously affected mentally for the purpose of discussing their problems with them and, if necessary, recommending them for institutional treatment. This is a wonderful service. Thanks be to God, as Deputy Andrews said, the time has come when people no longer hide this illness and hide those afflicted away from the public gaze. The problem is now brought out into the open and the patients visit clinics in the same way as other patients visit clinics. We have made a great deal of progress in Mayo.

I should like to acknowledge here the help we get from voluntary organisations all over the county. Deputy Andrews said that, because there were so many organisations, there was at times overlapping, but not intentionally. As a member of a local authority and a public representative, I have had half a dozen different groups on occasion phoning me about the one patient or the one problem. That is a waste of my time. Now I am not critical of these people. I admire their efforts and their charity and, so far as I am concerned — I am sure the same goes for the Minister — I am glad to help and to acknowledge their good work. But, as I say, there is at times a little bit of overlapping. It is grand to think we have such charitably disposed people prepared to help in such a generous way.

The Minister has dealt with the problem of the diabetics. His action has been appreciated by many throughout the length and breadth of the country. I want to make another appeal to him now on behalf of those who suffer from rheumatism, particularly arthritis. I know a great many of them. The problem is growing. Young people are afflicted. The pattern has changed since I was young; then it was quite usual to hear those in their sixties and seventies complain about their pains and aches. There was not much one could do for them. They just suffered on. It would be a wonderful help to present-day sufferers, particularly the young, if the Minister could build up a service for the treatment of arthritis and rheumatism generally. If he does so he will have the prayers and good wishes of thousands of people and, no doubt, at the end of the road he will go where Deputy Dillon said he would go to his eternal reward. I am sure the Minister knows people who have to pay as much as £2 or £3 a week for expensive drugs. If proper treatment were made available these might become useful citizens making their contribution to the community. It would be good economics, therefore, to come to their assistance.

The dental service in Mayo works on a pretty sound basis. The dental officer is a first-class man. He bends over backwards to serve all, but he is a little bit understaffed. Why that should be I cannot understand because a great many qualify in dentistry every year. Recently in Mayo I gave it as my opinion at a meeting of the county council that we were possibly not as generous with our dentists as they are in Britain and elsewhere, but I really cannot accept that argument because I have three cousins in dental practice, one here in Dublin and the other two in England. One of those was in America for a time. I pleaded with them to come back and work here, in the country in which they were born and reared and in which they got their education. They pointed out that they were doing well where they were. Now I would not ask our Minister — God forbid that I should — to copy the health scheme they have in Britain or follow their system because I believe there are certain gentlemen there who want to get rich quick and they employ Irish dentists to fill in forms, whereupon they get so much from the State. There are wholesale abuses of the health scheme in England. Our own nationals go over there and get whatever attention they need. Where that kind of thing goes on there are bound to be abuses. I believe the day will come when Britain will no longer be able to finance the present scheme.

The Minister should try to find out why those who qualify in dentistry here are not prepared to work here. If it is a question of salary then possibly some extra remuneration might be worth while because defective teeth can cause a dozen and one other diseases. I know hospitals here to which patients were sent and it was discovered that the root cause of the trouble was defective teeth and the patients had, first of all, to go to the dentist to have extractions done. There was consequent serious delay in the hospital as well as general confusion and inconvenience. The Meath Hospital in Dublin are very particular about tooth decay.

I am sure the Minister would be able to make out a list of dentists who would be prepared to come back and work with us. Indeed, I might be able to give him some names myself. We are not the worst off in that regard in Mayo. I do not wish to be critical of an adjoining county but it would seem that the people in Sligo have no dental service at all. The matter was brought to my attention by reason of the fact that a nephew of mine resident in that county and attending the local national school in the Kilglass area needed dental treatment to which he was entitled under the schools medical service. It was impossible to pin down the Sligo local authority in respect of his entitlement to benefit. The child was operated on in St. Mary's, Phoenix Park, Dublin, and the parents were told that the liability for payment rested in the first instance with the Sligo health authority, who would, I fear, need to put their house in order.

I am grateful to the Minister for his courtesy in listening to my few remarks. He is no doubt as familiar with most of the matters I have mentioned, as I am myself. He is very active in his constituency and does not in any way neglect his constituents. I know he is available to the humblest as well as to the biggest of them. I heard it said of him by a neighbour just a few days ago that he is very approachable. I thank the Minister for the help he has given to us in Ballina. If it is possible to have any extensions carried out to Swinford hospital, it would relieve certain pressures on the county hospital in Castlebar. They are two little hospitals which have given great service.

It is useful to be able to treat people who may not need to be sent to the surgical hospital. Ordinary cases and maternity cases are dealt with there and it is a great benefit to the Swinford area as well as to adjoining areas. Were it not for the little district hospitals, which are in such good working order and where the medical staff and the nursing staff know every patient by his or her Christian name, the people in the rural areas would be much the poorer, not alone financially but from the point of view of peace of mind. They are not used to the hub-bub and excitement of city hospitals or even, for that matter, of the hospital in Castlebar. We appreciate that the Minister is doing his best for Mayo and for the country generally. Indeed, the members of the Mayo County Council have expressed that very point of view. We trust he will ever be aware of the many problems which exist in our county, with most of which he is as conversant as I am myself, and that he will do the best possible for the general good.

Mr. Wyse

I shall not delay the House because I should only risk the possibility of further repetition of what has already been said. We are all very critical of the costs of health services and, yet, the various health authorities are making greater demands for improved health services. Furthermore, the Minister is criticised in relation to the burden of rates and that is a very genuine complaint.

There is very little talk as to how best the community can co-operate with the Minister and the local authorities in effecting economy in our health services. The time has come to examine the complete picture of our health services and see where some economy can be effected through coordination and co-operation. Substantial sums are spent year in and year out on institutions and hospitals for the care of old people, but the old people do not welcome it. The homestead and the corner by the fireplace mean more to the old man or the old woman than the thousands of pounds being spent on providing certain comforts for them in institutions and hospitals. The sooner that fact is realised, the better for all.

The time has come for a radically different approach to this aspect of our health services. Recently, in Cork city, a group of people got together and organised community centres in the various parishes there. The first job was to co-ordinate all the services so as to work as one unit. That has a greater efficiency potential than to have all the services working as separate units. They are now providing meals on wheels and a television room where the old man or the old woman can be brought daily. They also provide daily meals and transport old people to clinics for various services; they take them to Mass and call at their homes to keep them company. To my mind this is a most concrete approach to this question of the care of old people. Not alone are these people providing a service for old people but they are doing good for themselves because eventually this work will result in a very big reduction in rates.

In regard to mental services, we very often hear of medical staff seeking people's co-operation in their particular work. Often we hear about an unfortunate person getting treatment in a mental hospital and then after his discharge he finds that his path leads back once more to hospital and again he is shut behind the four walls of that hospital in an atmosphere which perhaps was responsible for first putting him there. Would it not be a good thing if such people could be brought to a community centre, encouraged to mix with people, brought to the realisation that they have returned to their community and that they are welcome? There is a tremendous amount of loneliness in our midst and we are inclined to turn our heads from it. Recently I was looking at a document entitled "Cork Community Centres" which states in answer to the question "What is a Community Centre?":

A Community Centre is a system which is intended to meet the total needs of a given locality or group of people. It represents their determination collectively to provide themselves with amenities and services which they (and their families) could not otherwise enjoy. It also reveals their practical concern for those members of their community who are in special need.

The special feature of a Community Centre, however, is the involvement of the local people themselves in meeting these needs.

This is an education for people, to help them understand the needs of others and it brings about harmony in the community.

An Leas-Cheann Comhairle

Would the Deputy give the title of the document?

Mr. Wyse

It is a document issued by the Cork Community Committee on the 5th July, 1968. I am very much interested in this because I feel that an economy can be effected here. I want to congratulate all the people in our city who have dedicated themselves to bringing about perfection in this kind of work. It has been said here that people who reach retiring age have little or no outside interests but I think that they could find a great deal to interest them in work for the community. We have seen how people who retire very often do not live for long after they have retired. There is no necessity for this because people can create work, they can give themselves up to the community and to those less fortunate. I see no reason why people who have retired and who still have their health could not interest themselves in working for the less fortunate people in our midst.

In regard to the physically handicapped, there is an urgent need for the sheltered workshop. Many physically handicapped people can do much for the community and help to build up the economy if only they are given the chance. The opportunity they seek is to be brought into a sheltered workshop where they can be trained and thus help to maintain themselves. Indeed, many of them have to maintain other members of their families. I would like the Minister to give careful consideration to this matter and I would also ask him to give grants, where possible, to groups of people who are rendering a service to the community. In Cork we are getting the greatest co-operation possible from the health authority and its officials. Many people would embark on this kind of work if moneys were made available to them.

I should like to congratulate the Minister on the document which he issued about the care of old people. This merited the closest attention possible from local authorities. In the city of Cork much of the planning in regard to community centres was based on the contents of that document. I should also like to stress the great urgency that exists for an emergency service at night in regard to the availability of doctors. After a certain hour at night it is very difficult to get a doctor to attend a person who has become ill. The medical profession have some obligation in this respect. There should be some way of providing such a service at night because a life may be at stake if a person becomes suddenly ill. Very often one has to walk the streets searching for a doctor. People who have family doctors are all right but outside of that there is difficulty. I should like the Minister to discuss this matter with the medical profession to see if some kind of night emergency service could be set up. Finally, I should like to say that I know of the Minister's dedication to the question of the care of the aged and I know that he will not fail them in regard to providing the money necessary to establish this kind of service which eventually will effect economies on the administrative side of the health services.

Mr. S.D. Barrett

There is always the danger when we approach an Estimate such as this that we would approach it with blunted critical faculties and that we would be inclined to say to ourselves, and indeed to the House, that every penny is well spent. One can see it is largely true to say that because, were the money we are providing for under this Estimate not being spent, many people would have crossed the threshold of eternal bliss, to which Deputy Dillon referred earlier today, instead of being still confined to this valley of tears. It may be a doubtful benefit to get from the expenditure of so much money, but it is our duty as Christians to maintain the lives of our citizens as long as we can in health and in comfort.

I remember having an experience which made me very wary of Estimates such as this. Not so many years ago I went to Scotland and left behind me a small tube of ointment which I got under prescription here for 6s 6d. I had the prescription with me but I forgot the ointment. It cost the British taxpayer £1 10s 10d by the time I had gone through the red tape of the British Department of Health to get that ointment. I was not allowed to pay for it myself but the 6s. 6d ointment cost the British taxpayer £1 10s 10d. From that point of view I would urge upon the Minister to cut out as much red tape as possible in the administration of his Department.

Deputy Wyse spoke about economies. I agree wholeheartedly with him both in regard to the economies he suggested and in regard to other economies which rest, not with this House, but with the administration of health authorities, which are to get £220,000 out of this Supplementary Estimate of £1,300,000. We should remember that we are spending something like £26 million this year on health and we should be very careful not to take the view that, against the background of such a large amount, small economies should not be effected.

Mr. S. Flanagan

The £26 million is on the Exchequer side alone.

Mr. S.D. Barrett

Yes. I find that there is money needlessly given out by health authorities either by way of medical cards or other benefits which are dispensed by them. Where there is "lolly" you will always have locusts. You will always find the man whose virtues of thrift and personal pride are blunted by the fact that he can get something for nothing if he tries hard enough and if he goes to the right circles.

I myself, and I am sure most Deputies, certainly those who are members of health authorities, have been approached by people with a view to obtaining a medical card for various medical and surgical services for which they could well afford to pay themselves. I know cases where people with most comfortable means were afforded by the health authority these benefits to which they were not in conscience entitled. The duty is, in my view, on the health authority most scrupulously to scrutinise the circumstances of those who apply for benefits which are at the moment by law available only to people who are not able to supply them themselves.

I am sorry to say that I am quite certain that there are certain public representatives who can bully or frighten administrators in health authorities to give benefits to which the people who receive them are not entitled. This is wrong.

Mr. S. Flanagan

Hear, hear.

Mr. S.D. Barrett

This depresses me and it is something which in my view should be brought to the notice of those who administer health authorities and should be brought to the notice of the ordinary man in the street with an injunction to him that in decency he should not demean himself, he should not lose his pride, to get these benefits to which he is not entitled. In the sort of dispensation under which we live we are inclined to lose those virtues of pride and thrift. It would be a good thing if the Irish people were reminded on occasions such as this that there would be no need for quite an amount of the expenditure to which the Irish people are being put under this heading if the average man in the street maintained those thrifty habits, which were the pride of his forefathers, and put something by for the rainy day, invested in the Voluntary Health Insurance scheme and other schemes which are available to him to enable him to meet the contingencies which we, on behalf of the people, now have to meet by way of supplementary estimate for these thriftless, prideless people.

My heart goes out to anybody who needs, through circumstances outside his or her control, assistance from his fellow citizen. These people should be given it in full but it is sad to feel that some really deserving cases must be overlooked because others who were not as deserving and were not in fact deserving at all were given assistance from local or State funds. The really saddening thing about people who get these benefits is that under the present system these benefits are largely being disbursed out of the purse and the pockets of some sections of the community which may be looked upon as the really deserving elements.

I want to express at this stage my disappointment that the Minister did not avail of this Supplementary Estimate to make good a promise or a half promise that was made on behalf of the Fianna Fáil Party that something would be done to alleviate the call upon the rates for payment of health costs. I want to repeat the demand which has been made here so often during this debate for support from central funds for health expenditure. It is not being made purely with a political motive. It is being made by Deputies from this side of the House because they realise the iniquities which are being wrought by the system under which we operate at the moment. Fifty-five per cent of the expenditure of health authorities must be met out of the rates at the moment. While the Minister may say that that is not so and that 55 per cent of it is being met from his Department and 45 per cent out of rates I was quite satisfied, from what I heard of Deputy Richie Ryan's contribution to this house last week, that the real situation is that 55 per cent of the moneys for health authority expenditure is being met out of the rates.

Who will have to meet these payments? You have in one house a man with a poor law valuation of, say, £20. He is working and has good recompense for his labour, perhaps £20 or £25 a week. Two or three of his children are working and bringing in perhaps another £20 a week. Next door you have a poor widow who was left with a house as, maybe, the only inheritance that she has from her husband with little if anything coming into the house. Her rateable valuation is the same. The amount she will have to pay out in aid of her local health authority is exactly the same as the man next door who is figuratively as rich as Croesus. That is entirely wrong and the Minister has admitted that it is not by any means an ideal system. When one considers that roughly only one-seventh of the population are ratepayers it must be admitted that a most unfair burden is being placed on a minority of the people. I know the Minister must be very tired of hearing all this.

Mr. S. Flanagan

I am not a bit tired.

Mr. S.D. Barrett

It is no harm that he should hear it again and again so that his obvious resolution to do nothing shall be weakened. Last year our rates in Cork were £900,000 and they are on the million pound mark this year. Out of a rate of £5 2s 2d in the £, £2 0s 3d has to go for the health services. One would imagine that this is a matter of urgency and that the Minister should consider it so. As a matter of fact, the Minister has more than once indicated that it is a matter of urgency, but what do we get from him? In his introductory speech he said:

The question of the arrangements to be made for financing the health services for the year 1969-70 is at present being urgently considered.

This question has been under urgent consideration by the Minister's Department for the last two years. How urgent is it if it is taking all this period of time before something is done about it? The Minister in replying to the debate should be a little more specific than this and so give some meaning to the words "urgently considered". Can he give us any idea of what he has in mind and how the interests of the ratepayers are being considered? This is an urgent matter for every ratepayer in the country who is being increasingly mulcted year after year in the name of the health services.

Deputy Wyse and Deputy Andrews dealt with the provision of facilities for the care of old people. Apart from the fundamental charitable and Christian obligations involved in this, there is also a financial aspect to it which should be considered. If more medical care at home was provided, if more provision was made for giving the sons and daughters of old people some financial assistance to keep them going, then these old people would spend their last days at home and some of the burden would be taken off the rates. The sons and daughters would find it much cheaper to maintain them at home than having them in hospital beds. Only five per cent of the entire expenditure on our health services deals with home medical care and the expansion of that to take care of about 30 per cent of our people would be a very effective way of making economies.

It is only right to draw the attention of the House to the excellent work being done by the religious nursing orders, the St. Vincent de Paul Society and the meals-on-wheels people. But for them our health services would cost much more. It might be a good thing in the shadow of a general election to extend congratulations to one's constituents who are doing so much for the people, as Deputy Wyse did, but all over this country these dedicated people are not alone bringing Christian solace to those to whom they minister but they are assisting the economy of the country and the ratepayers.

I do not think we should be over-complacent about the services we have and the fact that we are spending £26 million on these services. From what I can see and from what I hear there is a vast territory still untouched due to inadequate services. People in my constituency are having to wait for weeks and months before they can have operations. These are not acute cases but they have to wait for five or six weeks before they can get a specialist to operate on them. We also have the problem of a shortage of beds for cases which are not very urgent. Again we have a shortage of nurses and at that I am not surprised. Deputy Kyne referred to the fact that a nurse working eight hours a day gets from £8 to £10 a week. I know that to be a fact and the same nurse, should she decide to emigrate, would receive £2,500 a year. I have heard of them being offered as much as £3,000 a year.

There is one thing of importance in certain areas and certainly in my constituency. Those who go to be treated by dispensary doctors go because they need the treatment and not because they like the doctor or the surroundings. It is wrong that it should happen, as it has happened in Cork, that a small proportion of the dispensary doctors do not treat their dispensary patients in the same way that they would treat private patients if they were in private practice. These dispensary patients are human beings like the rest of us and they have been forced to complain about their doctors to different public representatives because they are not treated with the respect with which they should be treated. It would be well if the Minister would make it quite clear that he and his Department would be quite merciless with doctors who forget that they are bound to give comfort and consolation as well as prescriptions to those who come to them. People have been left waiting for long periods in cold dispensaries and then they are being treated as they should not be treated. I would ask the Minister to make it quite clear that he will not stand for that.

The Minister said that we would probably have the Health Bill this week. I do not know if he was being over-optimistic but are we going to have the Health Bill this week? The Minister maintains a poker face but it is only fair that he should now tell us whether the Bill is available. If it is not available he should tell us why it is not. Furthermore, he should be able to tell us with more accuracy when it will be before the House. He was given an opportunity to introduce this Bill on 21st January and I would be very glad to know what is delaying it. There must be some good reason and, if there is, we would be glad to hear it. If there is a bad reason, we would like to hear it too and would like to criticise it and let the people know why this Bill, so long on the stocks, has not yet made the water.

Mr. Dillon

On a previous occasion, referring to the voluntary services to which several Deputies have paid tribute today, I suggested to the Minister for Social Welfare that a great deal of overlapping and frustration might be avoided if he had an annual meeting with various organisations who are engaged on the visitation of the old, the meals-on-wheels and other functions of that kind. I would now renew to the Minister for Health the suggestion that he, perhaps, and the Minister for Social Welfare would hold a combined annual meeting with representatives of these voluntary organisations (1) for the purpose of assisting them in the matter of co-ordinating their activities, (2) to pay them the compliment of letting it be known the value set upon their voluntary effort by the State. If the Minister should with his colleague resolve to adopt the suggestion, I suggest to him that he might with advantage invite the Council of the Apostolate of the Laity, recently instituted by the Hierarchy, to attend that conference and if they are at a loss for useful work to put their hand to, to suggest to them that he has certain lacunae in the social services that he would like to fill and would be glad to know from them what they would be prepared to do to help him to fill them on a voluntary basis as part of the work to which they have resolved to put their hand.

I was a little disappointed in reading the Minister's very comprehensive opening statement that he did not dwell more explicitly on the very crucial question of the future position of the religious orders in the nursing services of this country. This is a matter that ought to be clarified. There is very great misgiving widely abroad, not only amongst the religious, but amongst patients in hospitals, as to what the future role of religious in these institutions is to be.

I was interested to hear Deputy Dr. O'Connell speak of his American experience. I know Deputy Dr. O'Connell to be a humane man. He is also a doctor. He spoke of the admiration he had for the American system of bringing in patients on a Friday night, putting them through all their tests and having them out on the street again on Saturday morning. That is not our tradition of hospital treatment. Only a doctor unfamiliar with the atmosphere of hospitals and the whole procedure would contemplate bringing patients into the surroundings of a hospital, which are in themselves a considerable disturbance for the average citizen, never mind the simple person from the country, putting them through a series of medical and other tests and turning them out on the streets in the morning. It takes some time for a patient to adapt himself to the new surroundings of a hospital before he is in fit condition to face the ordeal of medical tests and examinations, all of which are quite a traumatic experience to such person. I also have had experience of American hospitals. May God deliver me from the prospect of having such institutions ever established in this country. Here we have nursing; here we have medical care. In America —I do not want to exaggerate — one sometimes wonders is one a patient or a corpse. Treatment is highly efficient but has that element of indifferentism in it which is the hallmark of the highly skilled technocrat but which is as foreign to the mind of religious dedicated to nursing the poor or the afflicted as anything one could imagine.

I understand, in the light of the several reports and the Minister's statement, that we are to have, in future, three categories of hospitals: (1) those run by the local authority; (2) those run, whether they be regional or general, by lay committees and (3) general hospitals run by the religious who own them and operate them.

I know perfectly well that religious are by their nature and by their vocation children of light. They have chosen the religious life as a life of dedication to afflicted elements in society but they do contribute to hospital administration a unique quality which no technocrats, however skilled, can give. I should be happy to hear the Minister say in his concluding speech today in regard to the general hospitals owned and operated by religious orders at the present time that it is his firm intention to provide that their ownership and control of these hospitals will continue and that he looks forward to such religious bodies being sustained on the one hand by modern administrative machinery, staffed by highly skilled personnel and, on the other hand, by medical advice councils drawn from the staff of their own hospital but that the ultimate authority in the hospital will vest in the religious who own and operate them. That that should be said specifically and categorically at this stage is a matter of urgent and vital importance if the whole precious Irish hospital system is not to stand in imminent danger of disintegration and if there is not to be created an atmosphere of distrust and suspicion between the Minister's Department and these hospitals which should not exist and I hope the Minister will be able to make a statement today which will make it no longer necessary to apprehend. I want to see these hospitals and these religious orders working with the Minister and his Department on a basis of the utmost confidence and with the complete assurance that they will have from the Minister and his Department unqualified support.

The time is running out before questions and I do not want to seek to develop an argument only to drop it in the middle. I have referred to the necessity in the hospitals operated by religious for adequate techniques for the administration of the vast institutions which these general hospitals are going to be in the future. That kind of advice is as necessary in a voluntary hospital as it is necessary in Guinness' brewery or Jacob's biscuit factory. These vast new hospitals are something quite new to our way of life and require an administrative machine as complex as that appropriate to a large industrial plant.

Progress reported; Committee to sit again.