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Dáil Éireann debate -
Tuesday, 25 Mar 1969

Vol. 239 No. 6

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

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

When I reported progress on Thursday afternoon last I was dealing with some of the disadvantages of institutional life, the defects thereof and also the cost of maintaining a child in an institution as against in a foster home. The cost appears to me to be different in each local authority. Some local authorities pay scandalously low amounts of money towards the maintenance of a child in a foster home. Roscommon pay 11/6d for a child under ten years of age and 13/10d for a child over ten years of age. I think this is criminal.

It is ridiculous that a local authority in the year 1969 should pay as low as this amount to keep a child in a foster home. When you bear in mind that we in Donegal pay £2 per week I work it out that it is costing an average of £3 6s a week to keep a child in an institution in Donegal. When you bear in mind that some institutions operate purely on the income from charity and that in Donegal as little as 10/- per week is paid to that institution, you then see that if these charitable institutions were not there this average of £3 6s a week would be increased.

I do not know the figures for the whole country in this regard but I take it that the average of £3 6s a week in Donegal can be accepted as being the mean average for every health authority in the country. When you consider that health authorities such as Roscommon pay 11/6d to have a child placed in a foster home and are prepared to pay £3 6s. to keep it in an institution, our sense of proportion, our sense of decency and our responsibility to society is certainly failing. Needless to say there is no health authority in the country paying more than 30/-a week for the upkeep of a child in a foster home except County Donegal. We are told that the Westmeath authority will apply a rate of £2 a week in the near future. It is a sad reflection on health authorities that such a situation exists in our society in this day and age. I make the remark that some of the health authorities are usually classified as being the cream of the country. For example, Dublin pay the princely sum of £1 10s 9d per week, Kildare pay £1 10s, Leix £1 10s and Wicklow £1 10s. Those figures are so scandalous that people in public life can no longer ignore them. I might also add that I think the national newspapers do not play a big enough part in making the people aware of the plight of the orphan child. When I was speaking here last Thursday I said I hoped the Minister for Health would have available today the figures for the entire country of children under 16 years of age in institutions. I do not know if the Minister has them available.

I do not have the figures unfortunately.

They would be interesting figures for everybody. Perhaps the Minister could supply them at some future date.

I would be glad to do so.

One of the points I would like to make in this debate is that there is so much accommodation needed for mentally handicapped and physically handicapped children that I do not think it is right that society should allow orphan children to remain in institutions and pay an average of £3 6s a week for their maintenance when there are so many potential, if I may use the word, foster parents who would be prepared to take a child into their homes. We all know that adoption is the right solution to this problem. That is not to be discussed in this debate but it is so closely linked with fosterage that it is very difficult to keep them separate.

There is one thing that I have been told in the last few days which I did not know and I feel it should receive the utmost publicity. Very often you find kindly people being encouraged to accept orphan children in their homes as foster children. They are paid these ridiculously low amounts by local health authorities for their maintenance. I believe that these people should be encouraged to adopt the children. I am told that if they do this they may still apply, if circumstances in the home warrant it, for the allowance from the health authority. I have no real authority for saying this but, if it is so, I believe that the Minister for Health, and his Department should notify all local authorities asking them to bring this fact to the notice of those parents who at the moment have foster children in their homes so that they may legally adopt them and still not have to take over the responsibility of society which they wish to share.

The criminal thing about this is that, while there are so many children in institutions, the demand to take them out, to have them fostered and adopted, if it is properly advertised, is greater than the number of children in the institutions. It just does not make sense to me that there are so many people who wish to adopt children and that there are so many children in institutions wanting to get out.

I know that certain societies have been in contact with the Department of Health recently. I know one firm of solicitors have been in contact with the Department of Health concerning a young girl. I do not wish to state the details here now but I feel that, if I did, there would be a lot of people in high places embarrassed. In the interests of all concerned I am refraining from going into the details. I have so much respect for the Minister for Health that I will pass copies of these letters to him and ask him to deal with them personally.

Some of the disadvantages of institutional life have been mentioned to me. One of the things that cannot be found in an institution is a mother. It is described here as a mother substitute. In normal families you have both male and female. You do not find this in an institution. It is usually all boys or all girls. A child in a foster home stands a greater chance of being legally adopted than a child committed to an institution. Incidentally, I understand that 432 children have been legally adopted by this method since 1953.

Adoption gives a new name to a child and a new security in life. One of the fears of a child in an institution is that something will happen when it reaches the age of 16 years of age. It does not have to leave at that age but there is this insecurity. If a child is in a foster home it can continue to live there as a member of the family. All these things have a telling effect on the personality of a growing boy or girl. I have no doubt that if we had found ourselves in this position we would have protested and would have what is commonly described as a "chip on the shoulder" complex.

A child in a foster home has a wider choice of employment. If a child is in a family circle his foster brother or his pal around the corned will mention that there is a messenger boy job down the street or a job becoming vacant in a local factory. This information is not readily available to a child in an institution.

In view of all these things I wonder why local authorities do not increase their contribution to foster parents. There are so many arguments in favour of fosterage and so many arguments against institutional life that we can no longer accept the situation where health authorities such as Roscommon get away with paying 11/6d a week for the maintenance of a child in a foster home and are prepared at the same time to pay £3 6s a week on average for the maintenance of a child in an institution. This is criminal and the sooner the problem is tackled and solved the better for all concerned.

The next point I wish to deal with is school medical inspections. In Donegal we have a school medical inspection and it is the greatest joke in any household. The school medical inspector arrives at the national school. Every child is examined, recommendations are made that teeth should be extracted or that the child should be seen by an eye specialist or some minor defect attended to. By the time that child is called he has either moved into the secondary school and is not eligible to be attended to under the school medical system or he has left school altogether and is in Glasgow or Manchester. The cost of inspection must be tremendous when we compare it with the actual services given. My eldest daughter had some slight defect in her ear which I knew nothing about. It was recommended at a school medical inspection that she should be sent to an ear specialist. She was taken from the national school before the school leaving age and went to a secondary school. Because she had left the national school and was now a student in the local convent, despite the fact that she was still under 14 years of age, she was not eligible for free medical attention. If you cannot perform the service, then you should forget about the inspection. It is a laugh; it serves no purpose whatever and the money could be better spent.

If a child qualifies for the school medical inspection, every defect discovered in that inspection will be attended to free, irrespective of the family. However, there is a ludicrous situation inasmuch as if the parent becomes alarmed as to the degree of the defect or illness before the child goes to school and takes the child to the local doctor or to a specialist, this invalidates the right of that child to avail of the school medical inspection system.

This is fair enough if the illness is not permanent, but in the case of physically and mentally handicapped children the right to avail of the inspection should apply prior to national school enrolment, because the treatment which a physically or mentally handicapped child will receive for the remainder of its life is more educational and physical training than medical. Therefore the Minister should accept a recommendation of the Donegal County Council — perhaps other health authorities have made the same recommendation—that a child taken to a school medical inspector, whether that child is on the roll of that school or not, should qualify for the facilities of the school medical inspection, particularly a mentally or physically handicapped child. There is one case I know of—I will not say where, but we can say it is not in Donegal—where the parents, who knew the regulations, had a child with a defect. Because they knew they could avail of the free school medical inspection they took the child to the inspector. Since it was discovered at a school medical inspection that the child had a defect, that child will receive treatment without charge for the remainder of its life.

Other parents who do not know they can avail of this inspection, although they may be at a much lower income level than the parents who know, in their anxiety to have the defect dealt with, will take the child to their own doctor or to a specialist. If the defect is subsequently discovered at a school medical inspection it does not follow that the same facilities will be afforded as in the previous case, and the parents will be asked to subscribe according to their means for the treatment of the ailment. This is an anomaly in the health services, and I know the Minister will be sympathetically disposed to deal with something which is not fair.

There is another anomaly I wish to mention. Middle-income group patients may elect to go to the local hospital whether they are attended by a private doctor or their dispensary doctor. If they go under their dispensary doctor they can claim the right to be charged a fee not exceeding 10/- per week. If they elect to go under the private doctor then they will be charged the full rate and will be classed as private patients; they will lose their middle-income group status. This applies only in hospitals that are run by that health authority. The patient could go to the private doctor, ask to be treated as a private patient and, instead of going to the hospital run by the health authority, be sent to an extern hospital If he enters an extern hospital instead of his own local authority hospital, he does not lose his status. I understand that these are regulations which the Department of Health allow health authorities to make. They have allowed the Donegal County Council to do it and I think it is wrong. The health services report which was laid before the Dáil in January, 1966, when the late Deputy O'Malley was Minister for Health, states at page 59 in relation to the cost of our health services:

The Government, having studied the issue, are satisfied that local rates are not a form of taxation suitable for collecting additional moneys on this scale. They propose therefore that the cost of the further extensions of the services should not be met in any proportion by local rates.

That was stated three years ago. At this very time almost every local authority in the country is protesting against the cost of the health services. The people in Dublin are protesting in the streets and asking the members of the Dublin Corporation not to strike a rate until the Government remove the cost of the health services from the rates. There is a similar situation in various local authorities throughout the country. We had a discussion on these lines at the recent estimates meeting in County Donegal. I must say I am in favour of the attitude adopted by various local authorities inasmuch as I feel strongly on this point. The system of collecting money by rates was never intended to finance health services on the present scale. In County Donegal the rate is £5 3s 6d in the £; £2 2s 2d of that is the cost of the health services.

The Fine Gael Party have revolutionary proposals in their policy document in regard to health and more will be heard of them in the not too distant future. The Government accepted the report on the health services in January, 1966, and the White Paper was debated at great length here three years ago, and the Government indicated, as quoted by me from page 59, that something would have to be done. I do not know when that something will be done but the sooner it is done the better. People in other parts of this small island have taken to the streets in protest against many things. I should not like to see that happening here, but people have the right to protest.

The present system of taxation on a rates basis is not a fair one and the sooner it is changed the better. As an interim measure the Government might be interested in accepting full responsibility for the upkeep of extern hospitals. If they are not prepared to transfer the cost of the health services to central funds they might, perhaps, accept responsibility for the extern hospitals. That might be difficult but, certainly, the problems would not be insurmountable. I expressed this opinion at a local estimates meeting and a member of the Fianna Fáil Party agreed that this would be a way of transferring the cost from the local authority to the extern hospital. If the cost of the extern hospitals were the full responsibility of the Department of Health then the hospitals would cease to be our responsibility. This is not the position in relation to many aspects of our health services. For example, the Department of Health will not allow the county manager to transfer a patient to an extern hospital unless he is unable to provide a service for that patient in his own local authority. It would be exciting to speculate as to the possibility of extern hospitals being made the full responsibility of Central Government.

I should like now to refer to one matter affecting Donegal, a matter that is nothing less than a national scandal. There was up to recently a hospital in Killybegs, St. Columba's. It was the property of people other than the county council until about ten years ago. The Donegal County Council had an option to buy it and they bought it. Tuberculosis has been eradicated and two, three or four years ago it became very obvious that St. Columba's hospital would cease to function as a TB unit. A committee in Donegal dealing with the problem of the mentally handicapped made overtures to the county manager and the county council. Members of the county council, including myself, tabled motions in support of the proposition that the hospital when it ceased to function as a TB unit should be handed over for the purpose of accommodating mentally handicapped children. Now, somewhere along the line, an association known as CERT succeeded in convincing a sufficient number of county councillors that they had a better claim to the hospital. Many reasons were put forward by officials as to why St. Columba's Hospital was unsuitable for mentally handicapped children — but people dealing with the everyday problems of mental handicap, people whose opinion and advice I accept and respect, could see nothing wrong. In fact, they had nothing but praise for St. Columba's Hospital. With the slightest of alterations it could have been made to cater for 60 mentally handicapped children. A religious order was interested in coming in to manage it. However, CERT, a hotel training body, persuaded the council, by a majority of one, to change its mind. This caused a certain amount of frustration to those dealing with the problem of the mentally handicapped and they were forced for their needs to buy an hotel. Let me put on record here now my very deep appreciation of the help the Minister gave; without our asking he made finances available for the purchase of the hotel.

I do not know who took the decision about Killybegs. The hospital was handed over to CERT, free; gratis and for nothing by the Donegal County Council. I am told the hospital could have catered for 60 mentally handicapped children. Last week I read in the local newspapers that the conversion of the hospital has cost to date £160,000. This is nothing short of a public scandal and I have tabled a question to the Minister about it. I hope he will see fit to have a public inquiry into the cost of converting a hospital into an hotel and causing the association dealing with the problem of the mentally handicapped to buy an hotel to convert into a hospital. This is an embarrassing scandal and someone must accept responsibility for it. I know the Minister had little or nothing to do with it, but I sincerely hope he will expose those responsible.

I had nothing to do with it.

I quite understand that. In conclusion, may I say that on the occasions I have visited the Department of Health, or the Minister's office, I have been received with the utmost courtesy and any problems I presented were dealt with to my complete satisfaction. At times I offer criticism, but I want now to give credit where credit is due.

(Cavan): I shall not delay the House but I should be lacking in my duty if I did not put forward my views on this very important Estimate. I do not envy the Minister for Health his job in coming into the House in an effort to justify the operation of a perfectly absurd system and to stand over the financing of that system in an unjust and inequitable way. I am satisfied the Minister is doing his best to operate a system which it is practically impossible to operate.

I wish to join with Deputy Harte in saying that whenever I had occasion to approach the Minister's Department or the Minister himself I received nothing but courtesy and co-operation. I am not saying that I always got what I sought, but I was always received in a gentlemanly and courteous way and the Minister explained the position to me and did his best to facilitate me.

The continuation of the policy whereby health is substantially financed out of rates is unjust and cannot be defended. We have in this country a situation in which rating authorities in the past have either struck rates varying from £4 to £5 or more in the £ or in which the majority of them have declined to strike a rate because they felt they were imposing a crippling burden on the ratepayers. I wish to repeat, and I am sure it is already on record, that between 30 per cent and 40 per cent of this huge rate is attributable directly to the Health Estimate we are discussing today. It is the duty of a Government or anybody else who imposes taxation on the people to ensure that this is done in a fair and equitable manner which will have regard to the capacity and the means of the people to pay. The system of rating at present shows a complete and absolute disregard for these principles, and I shall have a lot more to say on this matter on the Estimate for the Department of Local Government.

The rating system imposes a tax by reference to an artificial value placed on land and buildings. To appreciate fully the absurdity of the situation it is only necessary to recall that the last general valuation to fix poor law valuations in this country took place between 1852 and 1865. There has not been a general valuation since then — in fact it has been impossible to revise the valuations on land since then and there has not been a general valuation on houses or buildings. That valuation, known as Griffith's Valuation — I hasten to add it had nothing to do with the patriot Arthur Griffith, who I am sure would have been ashamed of it — took place between 1852 and 1865 and it is a well-known fact that before that valuation was completed it was already out of date.

Valuation placed on one part of the country was out of line with valuations placed on the rest of the country because the valuation process commenced in 1852 shortly after the Famine when famine conditions were taken into account, but when the valuation was completed in 1865 conditions had improved and the valuation was carried out in those circumstances.

I do not intend to deal in detail with the valuation of the country but it is necessary to give one or two examples to demonstrate the point I am making. There was a partial valuation carried out in certain areas at various times in this century, and within the last 30 years Waterford, Buncrana and, I think, portion of Dublin city were revalued. But when it came to the valuation of these areas it was found that, though it was necessary to quadruple or quintuple some valuations from, say, £5 to £25, it was found other valuations were adequate.

Therefore, in respect of areas that have not been revalued, certain buildings in this country bear a valuation of £5 and exactly similar buildings have a valuation of £25. That means under the present rating system the occupier of one property is paying a rate of £25 whereas his neighbour in an identical property is paying a rate of £125. This clearly shows the absurdity of the system.

Another point I wish to make is that even if the entire country were revalued — and according to a Government publication it would take at least eight years to revalue the buildings; but this I consider a conservative estimate and think 20 years would be nearer — and all holdings were equated one with the other, we can take a situation where there were two valuations of £20 each which was fair for each property concerned. One of these buildings is occupied by a widow whose husband left her in fairly bad circumstances. On her £20 valuation she would have to pay £100 rates which she could not afford. In the other building with a similar valuation you could have a wealthy person, a substantial businessman or thriving professional, and he would be called on to pay only the same £100 rates.

This is the system out of which we are financing health and it cannot be defended. I will refer to one Government publication and read from the Report on Valuation for Rating Purposes published by an interdepartmental committee in October 1965. The first recommendation on page 29 of that Report reads as follows:

The position in regard to rateable valuation is unsatisfactory and inequitable and should be remedied by a general valuation.

That is the method we are using to finance health. That is the yardstick by which we are raising millions upon millions of pounds from the people of this country, in an unfair and inequitable manner.

To conclude on this aspect of the subject, the Minister is quite naturally very conscious of the unfair method he is forced to use to finance his health services and, in his introductory speech, he felt impelled to defend himself against the criticisms which he knew would be levelled against him in respect of the huge amount of money being raised in this inequitable way. In the course of his opening speech, the Minister said:

Again I would remind Deputies that what the Exchequer pays must, of course, be raised from the people just as money contributed from the rates also must be raised. The only justification for a transfer of responsibility for any portion of the cost of the health services from the rates to the Exchequer is that general taxation is a more equitable way of raising money than by increasing local rates; but the fact remains that the total cost must be met by the public.

Agreed. If I were to search the Library of this House for an argument which would support the case I am making, I could not get a better argument than that used by the Minister in introducing this Estimate, because he says that general taxation is a more equitable way of raising money than increasing the rates. If that is so, the Minister has the remedy. He should use his influence with the Government to persuade them to do what is fair and just and honest. The wretched system of health services which has been inflicted on the people of this country for years should be remedied. He should remove health charges from the rates and pay for them out of national taxation. Then, in his own words, he will be raising money in a more equitable way. It is not good enough for the Government to send a spokesman in here to admit that it is more equitable to raise money by general taxation than out of rates and, in the same breath, to say that they will continue to raise it out of the rates in an inequitable, unfair and unjust way.

I want to go on record here as saying that there is a moral obligation on the Government to raise taxation in the fairest way possible. We have it from the mouth of the Minister that general taxation is a fairer method of financing the health services than the rates. There will be a lot more to be said on this subject when we come to deal with the Estimate for the Department of Local Government. I appeal to the Minister to go back to the Government and say that from now on they must remove the health charge in its entirety from the rates. That is their duty. I am not a voice crying in the wilderness. Every rating authority from Dublin to Mayo, and every local authority, are indignant at the bills that are being presented to them this year, and at the rates they have to strike. The health charge is responsible for approximately 40 per cent of the rates. Certainly it is nearer to 40 than 30 per cent.

In my opinion, the fact that the health services are financed out of the rates results in some counties in inferior and inadequate health services being provided. There are certain schemes which may or may not be adopted by county councils as health authorities. For example, I can point out to the Minister that in my constituency it is possible for a person in the lower income group to have his teeth extracted free of charge but, if that person wants to have those teeth replaced by artificial teeth, he must pay for them himself. That is because the Cavan County Council feel it would increase the cost of the health services very considerably if they were to provide free dentures. That is but one example of the way in which the health services can be affected by this system of financing.

So much for the financing of the health services. I want to come now briefly to another aspect of health which has been touched on by other speakers and in which I have been interested since I became a Member of the Oireachtas, that is, the hospitalisation of mentally retarded children. In my opinion, the Government have fallen down on their duty in this respect.

The Deputy will not find many to agree with him. I do not think he will find many Members of the House to agree with him.

(Cavan): The Minister knows that every Member of this House has had occasion from time to time to go to the Minister and to go to the county councils in an effort to have mentally retarded children placed in institutions. If the Minister is candid, and I am sure he will be——

(Cavan):——he will have to admit that even in the cases in which I have interested myself, there are children who have been on a waiting list for four and five years to get into an institution. That simply is not good enough. I can speak only from my own experience, and I know that there are many parents who have the problem of mentally retarded children and they are driven nearly demented in trying to get them placed or looked after.

I want to repeat that there are waiting lists and that children have to wait three, four and five years to get into an institution and, if the Minister considers that is a reasonable position, I certainly cannot agree with him. I have looked through the White Paper on Health, and I looked through the Third Programme which has just been published, and I could find nothing to suggest that there is to be a crash programme in relation to these children.

This is something which really cannot wait. It is something which must be attended to immediately. I do not know how many of these children are in homes throughout the length and breadth of this country awaiting hospitalisation. I know there are a substantial number of them, and I am satisfied that the problem is not being treated by the Government as seriously and as urgently as it should be treated. It is not being given the priority it deserves. We know from the Minister's speech that the population of mental hospitals has decreased considerably. That is a good thing. We know also that sanatoria throughout the country have closed down in recent years. That also is to be welcomed. I want to ask the Minister why some of these vacant places cannot be used to house these mentally-retarded children.

We had an example of this here in the field of education for normal children. We had really what could be described as a crash programme. We had post-primary education brought into operation very quickly within 12 months of its announcement. If that could be done in that length of time for the vast population, comparatively speaking, of normally healthy children, why cannot the Minister for Health and his Department do a similar job for these unfortunate mentally-retarded children? That is not an unreasonable request. I am sure in this day and age of pre-fabricated buildings it should not be difficult to provide the necessary housing accommodation for these children. I am surprised to hear the Minister appearing to be satisfied with the position or considering that a lot has been done and that substantial progress has been made.

I do not often hear Deputy Fitzpatrick talking in a way that shows that he does not quite understand his subject. It is not his form.

(Cavan): I do understand. I understand that there are children and parents waiting for years. So long as that is the fact, I say that the problem has not been tackled and has not been dealt with. I will await the Minister's explanation of the situation and his proposals for its solution.

There is only one other matter I should like to deal with and that is the Report of the Consultative Council on the General Hospital Services. Here I should like to compliment the Minister on setting up this council. I should like to compliment the members of this council on the expeditious manner in which they dealt with the task entrusted to them and in which they presented their Report to the Minister for Health. I should like to go further and compliment the Minister for publishing the Report so quickly. It is really refreshing to find a Government-sponsored committee getting down to business and dealing with a very complex problem like this in such a short time. I cannot get the date on which the matter was referred to the council but we all know that the whole thing was dealt with in a very businesslike way.

October, 1967 to July 1968. Seven months.

(Cavan): That is very refreshing. It gives people confidence in committees and councils of this nature. There is nothing so frustrating as to find some problem has been referred to a committee or council and then forgotten about for years. That did not happen here. I should like to compliment all concerned on the way they tackled it and on the expedition with which they dealt with it.

Having said that, I come now to something very near home in my own constituency. This Report proposes that a central hospital should be sited in Cavan town. This central hospital is intended to cater for the counties of Cavan and Monaghan, together with sections of Leitrim, Longford, Westmeath and Meath. In recommending Cavan town as a location for that hospital the council was influenced very much with the central location of Cavan town in relation to the region. A look at the map will prove beyond yea or nay that Cavan town is the ideal situation for that hospital. If the hospital were to be located in any of the other counties concerned it would not be completely central for the rest of the region. Furthermore Cavan town is right in the centre of the county of Cavan. Certain other counties are staking claims, or endeavouring to put forward claims, to have the location of this hospital changed but I feel that they are really doing this because they feel they have to do it. There were meetings called and held to claim the hospital for other counties, and it was admitted that geographically they were not at all suited for the site of the hospital.

I feel therefore that the Minister accepts this Report in general and that in particular he accepts it in relation to its recommendation that Cavan should have a central hospital. I am also pleased to note that when the council came to deal with priority on page 127 it stated that in view of the existing condition of the surgical hospital in Cavan the provision of the new surgical hospital at Lisdarn should be undertaken as soon as possible. I want to add my voice to the recommendation of this consultative council and to tell the Minister, as I am sure he knows, that not alone has the surgical hospital in Cavan outlived its useful life but indeed the St. Felim's Hospital at Cavan also needs replacement. I am informed that St. Felim's Hospital is about 150 years of age and that the surgical hospital has really grown from a small building which was known as the old infirmary, and is now a patchwork quilt going back a couple of hundred years. I do not wish to create uneasiness in the public mind but I know that the Minister has obtained advice from reliable sources to the effect that both St. Felim's Hospital and the surgical hospital constitute serious fire hazards. I am aware that that is on record in the Minister's Department.

Therefore, I appeal to the Minister to see to it that preparations are made immediately for the erection of this new hospital in Cavan. It is not difficult to make a case for placing this central hospital very high on the priority list. I say that because discussions have been going on about the building of a new surgical hospital in Cavan for the past 25 or 30 years and the records in the Department of Health will show this.

I do not wish to delay the debate unduly but it is a fact that the staff of the surgical hospital in Cavan are doing a very fine job of work under what would appear to many people to be impossible conditions. The same can be said for St. Felim's Hospital.

There is a very fine modern hospital at Lisdarn. This hospital was built as a sanatorium in the early 1940s but as a result of the progress made in the eradication of TB, it has been used for some years now as a medical hospital. There is ample room there for extension. The Minister knows all about that as he was down there last year at the opening of a new nurses' home. May I say that he was about the only one there in the line of a public representative? I say that only in passing. The Minister made a very good job of the opening without any assistance from the chairman or any member of Cavan County Council. He had to shoulder the entire responsibility for the opening of the nurses' home. However, I am sure that he noticed the very lovely setting of the hospital and the very beautiful grounds which are so well kept. I am sure, too, that he saw the ample scope for extension which would enable the hospital to serve as a central hospital in accordance with the recommendations contained in the Report of the Consultative Council on the General Hospital Services.

As I say, that hospital has been placed second on the priority list after Dublin. I would say to the Minister that Dublin is not badly off for hospitals. At least there is a choice of several hospitals here. I would appeal to the Minister to complete the work which was commenced 25 or 30 years ago by giving Cavan a proper surgical hospital and, at the same time, the central hospital which has been recommended.

In case the Minister has misunderstood me, I wish to say to him that I am not blaming him personally, operating within the finances and within the legislation at his disposal for any of the shortcomings in his Department.

In conclusion, I would ask the Minister to have another look at the problem of the mentally-retarded child and to treat the problem as a national one. I do not think there can be very much money involved in this but it would be a good thing if something could be done whereby the families who have healthy children could help the families who have the affliction of a child who is not just as well mentally as its neighbours.

Deputy Fitzpatrick is very happy with the Fitzgerald Report on the future of hospitals in this country. I suppose since Cavan has been chosen for a general hospital, one cannot blame him for this. He says that high priority should be given to the building of this new hospital in Cavan. However, to my mind the report was rather rushed and I cannot agree with Deputy Fitzpatrick on the report in so far as my part of the country is concerned.

Apparently, the commission recommended that the present county hospital in Kilkenny be downgraded to a community health centre, a recommendation that caused great annoyance both in the city and county of Kilkenny because people felt that the hospital should be upgraded instead of being downgraded and that it should be extended. I understand that the county council have been endeavouring for a number of years to have the hospital extended so as to enable it to cater for all those requiring treatment there. The Fitzgerald Report states that there is a modern county council hospital in Kilkenny with 166 beds. I agree with that statement. This hospital is the largest one of its kind in the south-eastern region. It is therefore very difficult to understand how the commission, which comprised men, all of whom were specialists in their own fields, could overlook the claims of Kilkenny for a general hospital. This hospital, with 166 beds, must cater for the needs of everybody in the locality. As I have said, the hospital is overcrowded and more accommodation is required.

In the county hospital in Kilkenny we have a specialist in maternity work. We are appointing an obstetrician gynaecologist. Application has been made to the Local Appointments Commissioners for that appointment. The idea of reducing the maternity end of it to what is known as a cottage hospital is, I think, altogether out of the question. The hospital is being run very efficiently. According to the report submitted to the county council the average duration of stay in the hospital over the past three years has been ten days, which is very short. Chapter 3 of the Fitzgerald Report says that the general hospital should not have less than 300 beds and serve 120,000 short-stay patients. Kilkenny has a population of a quarter of a million people within a radius of 30 miles and the hospital should be brought up to 300 to 400 beds. The report also states that Kilkenny is probably the most centrally situated of the three centres of Waterford, Wexford and Kilkenny. Deputy Fitzpatrick said that Cavan was chosen for the site of the general hospital because of its central situation. Here, the committee states in the report that Kilkenny is probably the most centrally situated.

There is a suggestion that the general hospital could be brought to Waterford. I do not say that Waterford should not have a general hospital if it is found necessary to have it but I do say that it should not have anything whatever to do with the claims of Kilkenny. Waterford are very good neighbours to us and we have no objection to a general hospital there as well as one in Kilkenny.

We have a Regional Orthopaedic Hospital in Kilkenny with accommodation for 90 patients. Again, another quotation from the report on an outline of the future hospital system is to the effect that when choosing a site for a regional orthopaedic hospital Kilkenny was chosen because of its central situation in that area. That, in itself, is a certain justification for the present hospital being made a general hospital. In addition, we have an auxiliary hospital in Kilkenny with 36 beds for patients transferred from the county hospital. We also have St. John's Hospital, Aut Even, which to a large extent might be known as a community health centre. Recently, a very fine wing catering for maternity cases has been added to St. John's Hospital and there is a first class operating theatre there. It has the services of a specialist in gynaecology.

The report of the commission states:

(1) We have chosen Castlebar as the General Hospital for Mayo in view of its central location in the county.

(2) Sligo Town is centrally situated in relation to Counties Sligo, Leitrim, and South Donegal, North-West Cavan and North Roscommon, and is a suitable location for a General Hospital serving the area.

(3) Our choice of Cavan as a centre for a General Hospital springs from its central location in the North Midlands area.

(4) The situation of Tullamore roughly half-way between Mullingar and Portlaoise, reasonably close to both and centrally located in relation to the whole area.

It is very difficult to know if all of these hospitals were chosen principally because they were in central positions and why Kilkenny should not also be chosen because it is also a centre in this particular area. The decision was that Waterford was a thriving centre and that there was an industrial estate there. I do not think that that should have any bearing on the general hospitals services in Kilkenny. If Waterford deserves a general hospital, by all means let them have it but it should not be a case of putting out Kilkenny for the sake of Waterford.

When tuberculosis was practically eradicated, the county council at that time closed down the sanatorium and transferred the few patients left to other hospitals. Likewise, when drugs became available for the treatment of fever we closed down the fever hospital. Therefore, it is obviously not a case of just wanting to get hospitals going in order to have a hospital in the place. All public bodies in Kilkenny feel that the county hospital in Kilkenny is a very viable unit. It is fully occupied practically all the year round. During the past three years, the average occupancy has been 80 per cent. It is very difficult to know how that hospital could be down-graded, how the status could be down-graded and how it could be made into a community health centre.

Apart from people visiting patients, according to the county surgeon's report, at least four emergency cases come in there each month to be dealt with and, if they had to go a further 30 miles, the health of those patients would be endangered by the travelling. I would appeal to the Minister to look again into this matter and, indeed, to come down himself and visit Kilkenny county hospital and see the position there. There were no public representatives on that committee and, even in the case of hospitals, public representatives could give advice on the siting of hospitals throughout the country.

I would appeal to the Minister not to accept this report without going more fully into it because we feel that we require the specialist services to which I have referred. One-third of Waterford is surrounded by sea and therefore nobody can come to the hospital from that area but Kilkenny is in the very centre of a large area and I feel we should get the benefit of this hospital.

I should be interested to learn when the new Health Bill will come before this House for consideration. Leave to introduce it was granted to the Minister at the Dáil session in the Mansion House on 21st January, 1969. Apparently there is general confusion throughout the country about the appointment of dispensary doctors and no permanent appointments can be made until the new Health Bill is enacted and the position is made clear and beyond all doubt.

On the subject of medical cards, I hold that every insured worker should have a medical card whether he is earning £15, £12 or £18 a week. It is a great burden on the average worker to pay doctor's fees and, oftentimes, it causes delay. These insured workers are entitled to free drugs and free hospital treatment but they are denied access to a doctor. I feel that that should be remedied and that every insured worker should have a medical card. Prevention is better than cure and oftentimes people delay too long either before attending the doctor themselves or sending the children to the doctor. It would be much better for all if they had early treatment.

I have great sympathy with the Minister in regard to the rates position. It seems very foolish for the Minister to send a memorandum to all counties asking them to reduce their health estimates. The Minister must know that the county managers had already revised their estimates because of the enormous increase this year. In Kilkenny the increase is 3/5d in the £, the equivalent of £64,000 or £65,000. This is an enormous extra charge for health and it is the biggest single charge for any service in the county. Therefore I would ask the Minister to increase the contribution to the rates in order to relieve the burden on the ratepayers to some extent.

I have every sympathy with the Minister who has some of the heaviest responsibilities of any Minister in the Government. I should like to say that anything I say criticising the operation of the Health Act is not to be taken as a criticism of the Minister. It should not be the prerogative of any Party to set itself up as the custodian of the health services; it should be the concern of all Parties to ensure that the best possible service is provided for all sections but especially for the poor, the aged, the infirm, the mentally handicapped and all those who through lack of personal resources are unable to pay for their health services. All Parties are deeply concerned about providing the best possible health services, within our resources, for all sections of the community. However, the big question remains to be answered: are we getting adequate returns for the huge investment in the health services? I regard it as an investment because on the health of the country depends, to some extent at any rate, the economy of the country.

In Sligo/Leitrim there is concern and dismay, and justifiably so, over the hardships being imposed on ratepayers, especially on those least able to bear them. In Sligo there was a demand for an increase of 7/- in the £ for health services. The tragedy is that when people start to look for those services for which they are paying such an enormous amount, they find that adequate services are not provided. The ratepayers are fully aware of the heavy burden imposed on them to finance the health services and they are also aware that these services fall short of what are required. I deplore the failure of the Government to take effective steps to find a solution to the problem of financing the health services other than from the rates. This is an outmoded and archaic method, a relic of the landlord days; it is inequitable and does not take into account the ability of the people to pay. The present arrangement under which roughly 50 per cent of the cost of the health services is borne by local taxation — actually in Sligo we pay 47 per cent — cannot be defended and if the Government have become so inept as to be unable to find a solution then they should get out and make way for a Fine Gael Government. We have a realistic policy which is to finance the health services of local authorities by way of contributory insurance.

The people in my constituency are very aggrieved because when the White Paper was issued a few years ago the then Minister gave the impression that the rates would be frozen at the 1965-66 level. Paragraph 116 of that White Paper stated:

The Government have decided to make arrangements which will ensure that the local cost of the service falling on the rates for 1966-67 will not exceed the cost of the year 1965-66.

That gave the impression to the ratepayer that the rates would be frozen, for the purposes of the health services, at the 1965-66 level but apparently the meaning of that is now being changed and it is said that that was for that year only. From that on we have had a huge and unjustifiable increase in rates. I believe the Minister was genuine when he wrote to the local authorities requesting them to reduce the increased amount for health services. Unfortunately, however, the letter did not indicate where or how those reductions could be made. The Minister genuinely thought that he could squeeze something extra out of the Minister for Finance. Even at this late stage I would ask him to endeavour to do so. I think he would have a pretty tough job but he should not give up trying.

I should like now to refer to the inadequacy of the health services in County Sligo. I think the Minister has a fair idea of the difficulty we are experiencing there. The school medical service, which should be the most important of all the services, is practically breaking down. We have no ENT specialist and we know that in children the care of ear, nose and throat is highly desirable. We have not had an ENT specialist for some time. I do not know where the fault lies because I know that every effort was made to get one. A specialist in Dublin even went across to England and interviewed three Irishmen who were qualified as ENT specialists there but they would not return home. I do not know if the Minister can do anything about this. Is it a question of money or conditions or equipment?

We have a long waiting list. I should like to compliment the Minister for assisting very much a few months ago when I tabled a question which brought out the information that there were 99 on a waiting list for ENT treatment in Sligo at that time. The Minister became very interested and we got a few beds here and there in different Dublin hospitals with the result that the waiting list was considerably reduced. I am sorry to say that it is almost as bad as ever now. I am sure the Minister appreciates fully the fact that children are unable to study properly and that their education becomes impaired if they have pain in their ears or if they have bad tonsils which require removal. We also have a long waiting list in Sligo for the removal of tonsils and I do not know what can be done about it.

The dental service in Sligo has practically broken down. We have only one dentist to cover the entire county. He is an excellent young man who has set his roots in the county. He was originally appointed as a school dentist and now he is overworked trying to look after adults as well as children. We have provided the money for extra dentists but we cannot get them. I do not know why. Providing one dentist for the entire county is only nibbling at the problem: we require at least two or three more. We are all conscious of the need for dental care. It is taught in school; there are charts on the walls explaining it and advertisements in the papers and on television but we have no dentists. We all like to see our children growing up strong and healthy but I fear that the approach to the dental service is appalling, at least in my county. A vast improvement is required and I want to impress on the Minister the necessity to do something about the position as soon as possible. I know that he is concerned about it and is aware of what is happening.

We have no orthodontic specialist and in this case there is a three-year waiting list. I am told by the county MOH that the list will probably become longer if things do not improve. I do not understand this position. I have a particular case in mind where surgery was required on the gum of a school child and when the parents approached the county MOH they were told truthfully that there was a three-year waiting list. They made their own arrangements and got the child into St. Mary's Chest Hospital in Dublin almost immediately. If they could get a child in there through a private practitioner and, if a vacancy existed, how is it that the county council could not get the vacancy?

We are told we cannot get a specialist to attend in Sligo but there is a specialist attending there monthly in a private capacity. If that is so, why cannot the local authority get him? They say he will not act for them. I should like to know why. As regards children whose parents have to send them to Dublin as private patients the local authority get them treated under section 25 of the Health Act but the cost of travelling to Dublin with the children — and especially if they are young the parents must go with them — is almost prohibitive. Afterwards, the parents must visit them and perhaps take them back to clinics in Dublin.

This position seems to me to be absurd and I should like the Minister to take special note of it. If there is a private specialist in Sligo for orthodontic treatment why do the county council not pay for the patient if he goes to that specialist? They say they cannot. There is something wrong but it is the ratepayers, the parents and the children in question who are suffering while all this tangle is being unravelled.

I want to refer briefly to medical cards. I heard some criticism here regarding the issue of medical cards and I am glad to tell the Minister that I have no complaints in this respect. I have found that each case in my county is dealt with on its merits. Where a case is genuine I find that the county manager, who is a very humane man, always issues a medical card. I have also heard Deputies discussing the issue of medical cards to old age pensioners. I find no difficulty in getting medical cards for old age pensioners. I do not think I have ever been refused a medical card for an old age pensioner. I would like to suggest that an old age pensioner, who has to go through a strict means test in order to get the old age pension, should automatically be issued with a medical card. I would welcome that very much and I suggest to the Minister that this should be done.

The question of drugs has been raised in this debate. Modern drugs especially are very expensive but I think they are worth it because if a patient can be treated at home with modern drugs then he is still able to work and contribute towards the economy of the country and is not a drag on the local authority by having to pay for him in hospital. However, there is one aspect of this drug business I would like to bring to the notice of the Minister, that is, that wastage of perishable drugs as a result of being kept in dispensaries can be very expensive. We find there is a big wastage in perishable drugs and I think the system of keeping them in and dispensing them from dispensaries should be changed and that they should be dispensed from chemists' shops. That would save money and it would save the patient a lot of trouble and waste of time in having to travel long distances to dispensaries. I know of a case of a woman who lived 25 miles from the dispensary where she got drugs for, I think, high blood pressure and due to some law she did not get them for four or five days. I think it was over the signing of a document or some technical point that she did not get them for that length of time. The woman almost died, even though there was a chemist's shop right beside her.

I would like to refer briefly to the dispensary service and to the lack of permanent doctors, especially in the west of Ireland. In my county there is no permanent doctor in Skreen and Riverstown and probably in other places as well. Consequently, there is no continuity of service. It is an absolute waste of time and it is not fair to the community as a whole to appoint temporary doctors where permanent appointments should be made. Any doctor appointed in a temporary capacity will not stay there. He will stay until such time as he gets a permanent post somewhere else. Then the position has to be advertised again and there is a great waste of time. The result is that in some areas weeks or even months go by before another doctor arrives. Consequently, doctors in outlying areas are completely overworked. It is absolutely ridiculous that doctors with pretty long experience, who are available, married and settled down in a place should go up for interview to the Civil Service Appointments Commissioners and on some technicality, are turned down. If they were good enough to serve the public over a number of years and the public were satisfied with them when they were working in a temporary capacity surely to goodness they should be appointed in a permanent capacity. I do not know what the Civil Service Appointments Commissioners are thinking about but I know one thing. They are not dealing with realities as we who live in the west of Ireland are and they have not a clue about what isolated places there are, what areas of scattered population there are in the west of Ireland. If they had, they would try to give us a proper service. If a doctor is appointed in a permanent capacity he has security; he is pensionable and he will stay but as things are in my constituency and, indeed, in other counties in the west of Ireland, doctors who are appointed in a temporary capacity will not stay.

We have a deplorable health service in spite of the increase in rates and everything else. I would like the Minister to take particular note of that. Coming from the west of Ireland he knows the difficulty of getting continuity of doctors if their appointments are not permanent. I would emphasise that point because there is one place in County Sligo at the moment where the people are ringing me up and writing to me asking why we do not give them a permanent doctor. We advertised for one but the doctor who came was a single man and was appointed in a temporary capacity. When he got a permanent post in another place, we were back again to square one and the people had no doctor. Outside doctors will not come a distance of ten miles. You cannot have a satisfactory service under these conditions.

I should like to pay tribute to the nursing profession. It is only when one is a patient in a hospital that one realises the importance of the work nurses are doing.

Nursing is a noble profession and deserves proper recognition. The only way to give nurses proper recognition is by giving them an increase in their salaries, by paying them just salaries. That refers not only to the nursing staff in county hospitals but also the nursing staff in mental hospitals and all other institutions. I am glad to say that in Sligo we will have a general hospital soon.

Hurrah, you are getting something in Sligo. Marvellous.

We are getting a general hospital and I know there will be a big increase in the nursing staff there. I hope provision will be made for the housing of those nurses. I would like to make a suggestion. I understand that the Great Southern Hotel in Sligo will be up for sale shortly. The Minister might think of having it purchased for a nurses' home. It would be an ideal solution instead of having them accommodated in different places around the town.

There is just one last word which I would like to say, and that is, on handicapped children. I know the Minister is deeply interested in this matter, as I am. I know he is very sympathetic towards the treatment of those unfortunate people. I understand that there are three categories: mildly handicapped, moderately handicapped and severely handicapped. The future of mildly and moderately handicapped children at any rate is at stake. For that reason they should be got at as early an age as possible so that eventually they can be trained to take their places in society as useful citizens. I am glad that the parents of those children are more conscious nowadays of the necessity to let it be known that they have handicapped children than they were heretofore.

I should like to pay a tribute to the voluntary organisations and religious orders who are doing a tremendous job in this field and particularly to the French Sisters at Rosses Point for the magnificent work they are doing for girls. They recently extended their premises and the Minister was down there and saw what they are doing. They are deserving of our best gratitude.

During the term of office of the present Minister a tremendous lot has been done in this field, there is no doubt about that, and I should like to compliment him very much on that. Nevertheless, we cannot rest on our oars. In my county the problem is in regard to boys. It would be an indictment of our society if we did not continue to pursue this question until we have it solved. It will not be easily solved but if the progress which has been maintained in the last couple of years can be accelerated we probably will be able to absorb them all in a few years. One of the problems here is getting the children at an early age. I had a case the other day of an application to Stewart's Hospital for a child of three years of age. There was a pretty long waiting list and they do not appear to be anxious to take them until they are five or six years of age. I am sure the Minister is aware of the great strain it is on parents, especially on the mother, to have such a child mixing around with other children in the home, especially young children. I am sure, however, that we can safely leave the matter in the capable hands of the Minister.

I want to say a word on old people. The only reason I mention this is that I have heard the words "county home" used. That term should have been dispensed with long ago. It is a relic of famine days and of the British occupation of this country.

There is a stigma attached to it that nobody likes. I never call our house of rest in Sligo a county home. We call it St. John's. The idea of putting elderly people into these establishments is wrong. The dignity of old age deserves special consideration and any institution, no matter how good, can never replace the independence of the home for an old person. They always like to die at home in their own bed, as they say. If something could be done to have them cared for at home they would be much more comfortable and satisfied and less expensive for the country. One way of doing this, possibly, would be to increase the old age pension. That is not a function of this Minister of course. There should also be constant visits from welfare officers. Of course the idea of old people living alone in isolated areas should not be encouraged. We have seen too many tragedies, people falling into fires and so on.

Coming back to the General Hospital in Sligo, which is nearing completion, I should like to see there a training centre for nurses, provided of course that the local authority would not have to finance the entire venture. I should like to pay a compliment to the staff of Sligo County Hospital who have worked under adverse conditions in overcrowded wards. I have actually seen three babies in one cot, beds down the middle and so on. Nevertheless, the matron and nursing staff had the compliments of all the patients I visited and certainly did tremendous work in adverse circumstances. When the new wing is opened they will be better off.

I should like to conclude by referring to the rating system and asking that some other system be devised for financing the health services. The day is coming when too few will be paying too much for too many and that will not be conducive to proceeding towards the creation of a just society.

My intervention in this debate will be very brief indeed but there are a few matters I should like to refer to.

I was a Member of this House in 1953 when the Health Bill of that day was introduced. I remember distinctly Dr. Ryan, who was then Minister for Health, informing the House in reply to a question that that Health Bill when it became an Act, would cost the ratepayer 2/-in the £. I remember that figure being queried at the time and Dr. Ryan repeated it. Within a year Deputy T.F. O'Higgins became Minister for Health. He, reluctantly I must say, decided to operate the Act introduced by his predecessor. He said he was willing to give it a trial. Unfortunately, that trial is still running. Instead of the Health Act costing us 2/- in the £ it is now costing somewhere in the neighbourhood of 30/- to 33/- in the £. Our forecast at that time was much more correct than that of the then Minister.

Some years afterwards a succeeding Minister for Health, the late lamented Deputy Donogh O'Malley, introduced a White Paper on Health. He told us he would follow it up with a Health Bill. We are still awaiting that Bill. We are now on the eve of the 19th Dáil and we all know that there is no hope of that Bill becoming an Act before the present Dáil ends. We are back to square one in so far as health is concerned.

We are addressing the jury or some such nonsense.

The jury is the people.

I do that occasionally, successfully. I hope I will be just as successful in addressing the Minister today. If I am I will be quite satisfied. They are a very important jury because they will bring in their verdict very soon and the defence may not like it. The prosecutor may have the advantage when their verdict comes in, and I am the prosecutor as far as the Minister is concerned.

Let me proceed from where I was rudely interrupted by the Minister. As a result of that White Paper there has not been a permanent dispensary doctor appointed throughout rural Ireland. There are a few exceptions. In my own home county the majority of the dispensary districts are manned by temporary doctors, doctors who are merely passing the time waiting to better themselves either abroad or in some permanent post. Until we can take the appropriate steps, we shall remain in that unfortunate position in which the people are the victims.

I was drawn away from the question of rates. Let me make an appeal to the Minister to try to lighten the burden on the ratepayers of Donegal. They are now taxed to the extent of £5 4s 6d in the £ of which, as I said before, over 30/- is for health services. I think it was the present Minister who said here two years ago that there would be no further impost on the rates in respect of the health services — and if it was not the Minister it was his immediate predecessor. He kept his word in that year, but we understood that as and from that day there would be no further increase in the charge on the rates for health services. I would appeal to the Minister to ease the rates burden, particularly on the people in the rural counties. If he does that he will be doing something which will be greatly appreciated.

The last speaker, Deputy Gilhawley, referred to the County Hospital in Sligo. I am very glad to see a county hospital in Sligo, but I must protest when it is suggested that a regional surgical hospital be provided in Sligo for the people of south and south-west Donegal. There are ample locations and facilities for a major surgical hospital in South Donegal, and I sincerely hope these services will be provided there. The Minister and the Minister's colleague, the Minister for Social Welfare, are aware, as I am, that the people down there are protesting strongly at the fact that they are going to be deprived of a surgical hospital in the south of the county. I am not advocating any particular location for it. Nor am I saying that a new hospital should be built in Donegal town or that the Shiel Hospital in Ballyshannon should be extended, but I believe that either of those sites is suitable for a surgical hospital for south-west Donegal.

While I am on the subject of south-west Donegal, let me tell the Minister I was in a town called Pettigo last night, the most forgotten spot in the Twenty-Six Counties. It has no industry, no sewerage, and no drainage of its rivers, and what is worse it has no dispensary. The nearest dispensary doctor to Pettigo is 14 miles away. If that dispensary doctor, who is merely doing locum in Pettigo, is busy in his own dispensary district, one cannot expect him to attend in Pettigo. The people in Pettigo asked me last night to make an appeal to the Minister. In the Six Counties, within 100 yards of that part of the town of Pettigo which is in the Republic of Ireland, there are three excellent doctors in residence. Surely some arrangement could be made whereby these doctors resident in the Six Counties could attend patients in the Twenty-Six Counties and be paid a fee per capita or a retaining fee. That would solve the problem for the people living in this forsaken and forgotten spot.

In a little area called Lettercran the people told me there was a resident doctor within two miles of them, but if they wanted a dispensary doctor they would have to send to Donegal town, which is about 18 miles away. It appears that some short time ago, through the good offices of the Minister, one of these residents of the Six Counties undertook to do locum in the dispensary in Sligo but for some reasons which I cannot understand he received eight bogus calls in one night from a public telephone kiosk in Pettigo, with the result that he resigned from the dispensary and refused to do locum. This is something the Minister should deal with. I do not think it would require much capital, and I am satisfied it would be a great comfort to the people of Pettigo and the surrounding districts if they were assured of medical attention within a reasonable time when it was called for.

I should like to pay public tribute to the helicopter service, whether it is provided by the Minister in liaison with the Army or whoever provides it. It is doing excellent work. However, the expense of that helicopter service could be avoided if some arrangement could be made whereby the helicopters based at or near Derry City could be used for the transportation of patients from Donegal. I do not know whether this would work out economically but perhaps the Minister would kindly look into it to see if such a service could be provided. It would be more efficient and possibly more economical but certainly the helicopters would be available in all weathers, and that is the principal consideration.

My contribution will also be very brief. This is the third week that this Estimate has been debated and it is only right that such an important service, affecting as it does, every person in the State, should receive deep and mature consideration from Deputies on all sides of the House.

Everything that could be said about the various aspects of health, from the treatment of the mentally or physically handicapped child to the treatment of geriatric patients, has been said. I rise particularly to highlight the difficult task of the Minister in charge of such a service in facing this House and the local authorities. Many Deputies are also members of local authorities who are now in the process of striking a rate. We know the impact which the health services have on the rates, but in spite of this fact, about 95 per cent of the speakers on this Estimate have been looking for improved and more expensive services. Nobody doubts the desirability of every service advocated here, but all these additional services will cost money. This is what I find all along the line: we are there for eleven and a half months in the year seeking extra services, more doctors, more hospitals; then, when it comes to striking the rate, there is gloom and depression. It is only right to point out that, because of these services, the most needy amongst us can get the best specialist services they require. Lack of money does not militate against them. The best surgical and medical care is available to them. That is a tremendous step forward.

I am sorry some Deputies have seen fit to raise this matter of a former Minister saying comprehensive health services would cost only 2/- in the £ on the rates. What was 2/- worth at that time? We hear questions as to the value of the £ in 1939, 1959 and today. What was 2/- worth in 1953?

The health services today are much more comprehensive than those envisaged when that statement was made. When money is available we should not have this niggardly approach to such a very important matter as the health of our people. These services are for those who are less well off. One has, of course, to exercise discretion. There is a limit to expenditure. No matter how desirable a project may be one must wait until the necessary money is available to implement a new service or improve an existing one.

I do not subscribe to the view that health services should be financed out of taxation. Were that to happen administration and control would be taken over by the central Government. There would not be the same personal approach that we have now. The rates are paid by those who benefit. At the moment we find it difficult enough to contain the demand for more services. We pay something like 50 per cent of the cost of the services. If we could demand services without having to pay anything from local rates towards those services I dread the thought of what the demands would be if the entire cost were administered by faceless men in some Government Department. The cost of the services would snowball all over the country.

I have listened to, or read, most of the speeches here. All aspects have been emphasised and dealt with. Voluntary workers are doing magnificent work. Nobody knows that better than I do. We have some wonderful voluntary services in Cork for mentally and physically handicapped children and for the aged. Patients are visited daily in their own homes. The demand for services like these will always be there and the recipients are most grateful. No stigma of charity attaches to this service. An old person very often needs companionship more than food or even warmth. We have experience of very good homes run by religious, homes in which, one would think at any rate, the aged should be glad to end their days, but they hanker after familiar surroundings, even though those surroundings may mean living in a thatched cottage without sewerage, water, electric light, or any other amenity. Keeping them in their homes is the best treatment of all. The trend now is towards that policy and the result is that we have in Cork shortened the institutional stay of the chronically ill over the last 12 months. The old people are now visited in their own homes. There are "meals on wheels" and other services provided for them.

We must be realistic in our approach to our health services. If we had unlimited finance and provided every service asked for there would still be people complaining and asking for more services. That is human nature. That has been the experience in countries which are wealthier than we are, countries spending far more on health services than we do. Human nature is insatiable. We must face that fact. All we can do is that which lies within our means.

One of the most unfortunate remarks ever made by a Minister for Health was that made by Deputy Dr. Ryan when he was canvassing support for the 1953 Health Act. He met the members of the different local authorities throughout the country and told them that the proposed health services would cost no more than 2/- in the £ on the rates. It was, no doubt, a correct assessment at the time but it has been widely and consistently misunderstood over the years and it illustrates something I want to develop. Dr. Ryan, then Minister for Health, was referring at the time to the services available prior to the 1953 Health Act and to the cost of new services in so far as they related to personal health services under the 1953 Act. He took a costing — it was a correct costing — and said that these new services would cost the ratepayer no more than 2/- in the £. I do not say it turned out to be precisely accurate and exact but it was a pretty good assessment at that time as to what health services were likely to cost.

The fact that he made that statement is recalled particularly during not the mating but the rating season, when the cost of the health services are brought home to each ratepayer throughout the country. At that stage every year people recall with some annoyance, frequently with frustration, the headlines set some 17 years ago when these services were first canvassed throughout the country at 2/-in the £. But what is important in this connection is that in the past 17 years most people interested in this problem have learned by experience.

I think all political Parties have learned. All of them have benefited by their learning, except one, and that is the Fianna Fáil Party who have not garnered any new ideas or new policies from what has emerged from the debates during the past 17 years. It is clear there is a fundamental difference of opinion between the Deputies who occupy these benches for the moment and those who occupy the Fianna Fáil benches on the very serious question of how to finance the health services.

We cannot but agree that within our resources we have the obligation and the duty to provide the highest possible standard of health services for our citizens who are sick, disabled and in difficulties. Nobody disagrees on that. There may be disagreement as to whether a particular service, a particular hospital or arrangement of hospitals, may be required in one place as opposed to another, but we are all clear that we should benefit from scientific advancement in other countries, that we should in so far as we possibly can — and it is not a question of cost — try to have the best standard of health services that money can buy. On that there is no dispute.

Where the disagreement arises is in relation to the manner in which these services should be paid for. Under the Health Act and under the financial provisions for the payment of Health Act services, the Government — they have been Fianna Fáil Governments over the years — have been consistently tied to the one simple approach that the health service must be paid for pound by pound from local rates and from central taxation — half and half — and that in this way only shall we finance our health services. That is an approach which is old hat and old fashioned but it has been the consistent Fianna Fáil approach——

Consistently not so.

There is a slight difference but it does not matter.

Slight differences do matter.

As a result of pressure from these benches——

——the fifty-fifty arrangement has been slightly balanced.

Much further than that.

The position is this: the fundamental objection still remains which was raised from these benches 12 years ago and which has been repeated time and time again, year after year. It is that the exigencies of the local rating situation in each local authority area has a decisive effect on the standard of our health services. Of course, no Minister for Health worth his salt — I am glad to say none of them has fallen down on this — would allow a local authority to arrive at the position in which, merely because of the impact on rates, an essential service required for the assistance of sick people would be refused.

I am not saying that efforts in this direction have not been made. They have been made but the settled approach of Ministers for Health and the Department has been that these services must be provided, so there has been a situation in which the Government, correctly in this respect, laid down a standard of health services and insisted that these services be put into operation; and down in the local authority area these services have to be paid for.

Of course we have gimmicks like the recent circular the Minister for Health sent out to health authorities throughout the country telling them to watch very carefully how they were pricing and costing their health services. It was a gimmick and it was intended to be nothing else. It was an attempt to build up a kind of window-dressing to the effect that local authorities had the initiative and the responsibility in this matter, which they have not got.

These services having to be provided for, with costs going up and the money having to be found by a charge on local rates, then, of course, bedlam breaks out. People then find that the rates rise, on an average this year of something like 11/- in the £ throughout the country, attributable to health services. There are mass meetings and protests and the local representatives are approached and put in the dock because this or that rate may have to be struck.

But the responsibility is not theirs. The fault lies in the daft policy that is behind the present health legislation and health schemes. Why—I hope the Minister will explain it—should we continue to finance our health services in a manner that has been rejected by most other countries? It is the kind of thing they did in the Victorian days when they abused the poor rate in order to save the privileged from the burden of taxation. They put it on the poor rate.

Today, this discarded mentality still imbues the financial provisions of our health services. We reject it. Apparently Fianna Fáil still retain this approach and as long as they retain it, when our rating season comes each year people will remember the 2/- in the £ and with bitterness the impact on them in local taxation of the cost of these services. Of course many of the ratepayers who are protesting are crying out : "Why should we be taxed some 40/- in the £"— in Donegal it is something of that order—"to finance a service in which we are automatically deprived of any opportunity to share?"

I hold no brief for them, but there are landholders throughout this country whose valuation exceeds the statutory limit, and they are excluded from any benefit under these services. They have to pay for them. There are people who are running very small businesses whose income exceeds the statutory limit. They have to pay for these services and they are not entitled to benefit from them. Of course they protest, of course they express their annoyance, but the system continues.

I have said before and I will say again—because this I anticipate is the last opportunity I will have of saying it in this Dáil: I hope I will have the responsibility of doing something about it in the next Dáil — that it is possible so to organise our health services, with a sensible approach on the principles of social insurance, so that with a small weekly charge imposed on the head of every family an insurance fund could be created, removed entirely from the exigencies of the local rates and not dependent in any way on the difficulties that arise from different problems in different parts of the country, a fund which would finance expanded and comprehensive health services.

I have said that can be done. I have studied the way in which it could be done. I have benefited from seeing how it has been done in many other countries. When I raised the details here in a Dáil motion some years ago, the Government set up a Select Committee—I suppose to try to prove me wrong—and that Select Committee sat and heard evidence. It was led by the then Minister for Finance who was anxious to establish, if you please, by calling witnesses, that there was no demand for an improvement in our health services, that there was no demand for a choice of doctor, that there was no demand for home nursing, and no demand for the various improvements that we had advocated from these benches.

Of course, when he called witnesses he got his answer very quickly. Towards the end of that Select Committee I handed in a detailed memorandum dealing merely with the general medical services. I handed in a detailed memorandum showing percisely how our general medical services could be organised, precisely how they should be costed, precisely what it would mean to the head of every family—something around 2/- a week. That memorandum is before the Minister at this moment I have no doubt. Certainly it is available in his Department. I challenge the Minister and I challenge the Fianna Fáil Party to demonstrate now any way in which the details of that scheme could not be fully operated.

Can I get in then?

Indeed it will be a long time before the Minister gets in.

I am not worried about that.

I am giving the Minister plenty of notice. He has all his officers available to him. I challenge him to demonstrate in Dáil Éireann how any detail of the Fine Gael proposal could be found to be unworkable. That is a fair challenge. I want to go further and say that while this was not the object of our proposal a side effect would have been that for the past ten to 12 years the cost of the personal health services would have been removed from the rates, and they would have been financed from an insurance fund, and much of the present disquiet and difficulty and clamour about the rates throughout the land would not have occurred.

I am aware that since the time this memorandum was prepared the costings will have changed. I have no doubt that the costing of the weekly insurance payment as indicated at that time will have increased. Money has fallen in value. Prices have increased and costs of medical services have changed. Providing you get away from the straitjacket of the Fianna Fáil health policy —this you must be free to do—once you can get away from that, once you accept this principle that people should when they are well pay for the day they or their neighbours are ill, you can make progress and you can advance. If you continue with an organisation of health services which is aimed purely at the day when people are ill you get nowhere.

The health services we have at the moment are designed to ensure that the patient ends up in hospital. Our health services at the moment are a conduit pipe from the sick man's house into a hospital bed. There has been no development of adequate home medical aid. There has been no development of an adequate kind in relation to proper home nursing. We are still concerned with providing through designated doctors, not nominated by the patient, services in which they look at the person, take his temperature, telephone for an ambulance and cart him into hospital. The result has been that the development of a comprehensive medical service is as far removed today as it was some 12 years ago.

I assert that the present cost of personal health services can without difficulty be removed as a charge from the rates and become the responsibility, easily discharged, of heads of families. That is one end of it. I also assert that as a result of a new approach to the health services the cost in our general hospitals could be dramatically reduced. I move to report progress.

Progress reported; Committee to sit again.
The Dáil adjourned at 10.30 p.m. until 10.30 a.m. on Wednesday, 26th March, 1969.