Committee on Finance. - Health Bill, 1969: Second Stage.

I move: "That the Bill be now read a Second Time."

The provisions in the earlier Parts of this Bill deal with the establishment of a new structure of administration for the health services and with the financing of the services in the future: the later provisions consolidate much of the present law on the health services and propose a number of changes in the services. The logic of the draftsman's science requires that the Bill be structured in this fashion, but I do not think that, in speaking on the Bill, I should follow the same order, because the nature of the health services, and not how they are administered, is of more fundamental importance. Therefore, I propose first to speak on the provisions on the services in Part IV of the Bill.

This Part essays to consolidate most of the present law on eligibility for the various health services, to propose a number of changes in those services and to express in a clearer and more codified form the general policy of the Government on their development. On this occasion I do not, of course, intend to go into detail on each of the provisions in this Part of the Bill: that will be a matter for Committee Stage. Rather is it my intention to speak on the general policy underlying this Part and to refer only to the more significant changes which it proposes in the law on the services.

The 1966 White Paper made it clear that the present Government had not accepted the proposition that the State had a duty to provide unconditionally all medical, dental and other health services free of cost for everyone, without regard to individual need or circumstances. Their policy has always been to design the services, and the provisions on eligibility for them, on the basis that a person should not be denied medical care because of lack of means, but that the services should not be free for all.

In the application of this policy, about 90 per cent of the population have become eligible for hospital and specialist services but, as family doctors' bills do not impose the same financial burdens, only 30 per cent of the population is entitled to the general practitioner service. The White Paper went on to say—

By following this broad principle, there has been a more effective use of the necessarily limited proportion of the national product which can be devoted to the public development of health services than if an effort had been made to develop on a much broader basis a scheme with the features of a comprehensive free-for-all national health service. The present services meet the essential needs of the population: in so far as it is now proposed to make changes in them, these changes are justified in each case by special considerations, which are mentioned in Part III of the White Paper. With increasing prosperity in the future it should be possible to make these changes without adverse effect on the present services. The social development of the State, in the Government's view, calls for future changes such as are now suggested but the Government would emphasise that their proposals do not represent a radical departure from the principles set out in the preceding paragraph.

The basis for the Government's health policy, as thus expressed, remains unchanged and I should make it quite clear that there is no intention in the Health Bill to change it.

Events since 1966 have, if anything, strengthened the case for this approach to eligibility for health services as against a policy in favour of having a comprehensive free-for-all service. This issue was debated at some length a few months ago in this House and I do not intend to dwell on it at length now. I will but point out that our health services which, in 1965-66, cost about £33 million to run, are now costing about £51 million, including the deficit payments to voluntary hospitals. This increase has come without any spectacular changes in the services: it has arisen from increases in remuneration and prices and from some steady improvements in the existing services. As the House is aware, this increase in expenditure has not been unattended by financial problems at local and central levels.

To make a big change in the scope of the services, whether by making all the services available to everybody free of cost or by extending general medical services to the middle-income group, would mean that, apart from the ordinary rise in expenditure which can be expected to continue, an extra sum, which I estimate could amount to a minimum £20 million a year, would have to be raised in some way. It should not be assumed that this could be done by any form of central taxation, and certainly local taxation could not be called upon to bear a share of such an addition in expenditure. Neither should it be thought that insurance contributions would provide a source for such expenditure on such a scale, whatever advantages they might have as an ancillary source of finance.

If, to pursue a particular political philosophy or to attempt to meet an alleged public demand, this Bill were to have proposed a widening in eligibility so as to admit all citizens to all the services, or most of them to most of the services, this would have been an irresponsible and foolish move. For we must recognise that the amount of public finance which is available now for the health services, or which will be available at any time in the future will be limited. If the additional money which can become available for the services is dissipated in an attempt to widen unnecessarily the groups eligible for them, then it logically follows that there will be little if anything left for the improvements in the essential services for the groups who have a real and clear need for them.

What money will be available must be concentrated on the improvements on services for the care of the aged, for the development of general medical and nursing services for the lower income group, for bringing up to date our facilities for the treatment of mental illness, for meeting the large problem of the care of the mentally handicapped, for developing the preventive child health services and for other essential projects of this nature. Therefore, in putting this Bill to the House, I make no apology because it does not contain any spectacular proposals on the extension of eligibility for services. That it does not do so is deliberate and well justified Government policy, as I have just explained.

Within this general framework of policy, however, the Bill proposes a number of important changes. The most notable of these is the intention, as expressed in section 56, to replace the dispensary system with a service offering choice of doctor in the general medical service for the lower income group, in so far as this is practicable. There seems to have been some misunderstanding of the intention behind this section and, indeed, Deputy Fitzpatrick in a comment when the Bill was published, suggested that the Government intended under the Bill to retain the dispensary system. This, of course, is not so. The dispensary medical service operates under section 14 of the Health Act, 1953. Dispensary districts are governed by section 51 of that Act and district medical officers for those districts are appointed under section 52. These three sections are scheduled for repeal by the Bill. It thus clearly sounds the death-knell for the dispensary system as we know it now.

The new legal basis for the general medical service will be primarily in section 56 of the Bill. Under that section and section 25 the new service can be organised by making arrangements with participating general practitioners in such form as may be negotiated. Section 56 requires that choice of doctor be offered in so far as it is considered practicable by the Minister. There is nothing sinister in this saver. Obviously, absolute choice could not be provided for in the Bill, as it could not be required of the health authorities that a choice be offered on, say, the Aran Islands or some of the remoter areas in the West. Apart from such areas, however, it is the firm intention to offer a choice of doctor by participating practitioners.

Perhaps more important, it is the firm intention for all areas that the present arrangements of separate premises and arrangements for public patients will be ended. The White Paper expressed the Government's proposals on this service as involving "substituting for the dispensary service a service with the greatest practicable choice of doctor and the least practicable distinction between private patients and those availing themselves of the service". This remains the Government's policy and section 56 of the Bill and the other provisions I have mentioned will provide the legal basis for this policy.

While this major change in the general medical service cannot come into effect until the Bill has been passed and the necessary ancillary steps have been taken, I can report much progress in the preparatory work for making this change. I have had a number of meetings with the Irish Medical Association and the Medical Union on these proposals and details of them have been discussed at several meetings between the organisations and my officers. Substantial agreement has been reached on most things in these discussions and the essential features of the arrangements for the new service which I propose following these discussions are:

Participation by doctors would normally be on the basis of an agreement with the health board;

An eligible person would, subject to certain restrictions—mainly as to distance—be allowed to register with any participating doctor willing to accept him and would be allowed to transfer to another doctor after giving proper notice;

Persons could be assigned to a participating doctor where this was necessary;

Special arrangements would operate for group practices and partnerships;

There would be control on entry by doctors into the service;

Future vacancies in the service would be filled by public competition;

Patients would normally be seen in the doctor's premises, but the health board would have power to make accommodation in clinics or health centres available to general practitioners where appropriate;

Special arrangements would be incorporated to keep doctors in remote areas.

Those who now hold posts as permanent district medical officers will be given guarantees in relation to entry into the new service which I have agreed with the profession and other doctors who are in general practice for a minimum period will also have an initial right of participation.

I must report, however, that up to the present agreement has not been reached with the medical organisations on the method of payment of doctors under the service. Both the organisations were required by resolutions of their members to seek payment on the basis of a fee for each item of service. I informed them that I would not favour such a system, mainly because of the complications and administrative expense in operating it and the difficulties in controlling abuses. Initially, I favoured a system under which there would be a flat comprehensive annual capitation payment for each person on a doctor's list, but to meet the views of the profession I subsequently told the organisations that I would be agreeable to a modification of this so that there would be a separate payment to cover the doctor's practice expenses, a basic annual capitation payment to cover ordinary medical care and medical attention and, in addition, special fees for unusual items of service. After further discussions on this, which did not, of course, commit them to acceptance of this concept in principle, I sent to the organisations on 14 February last a detailed statement on this proposal and on the rates of payment.

At a further meeting on 3rd April, the association and the union indicated that they did not consider that the rates of payment offered were sufficient and also made the case that my fears in relation to the fee-for-item-of-service method of payment might be allayed if the profession were to suggest adequate controls. I did not accept what they put forward in relation to the rates of payment which I had proposed but, before considering this particular matter further, agreed that a small working party should be set up to consider the suggestions which they would wish to put forward on the controls needed under their suggested system of payment. This working party is now being set up and I expect it to report shortly. I cannot, in the circumstances, report to the House that the details of the system of payment have yet been agreed on, but I can assure the House that the professional organisations and myself are very anxious that this issue should be resolved soon. This is desirable on several grounds, in particular to end the uncertainty in relation to the future which has seriously affected the operation of the dispensary system in some areas.

It is intended that, under this new service, drugs and medicines will, as far as practicable, be issued through retail pharmaceutical chemists. Again, in preparation for the enactment of the Bill, this has been discussed with the retailers and also with the manufacturers, importers and wholesalers of drugs. A large measure of agreement has been reached on the means by which such a service would be operated and I foresee no insurmountable obstacles to agreement on the final details of the operation of these arrangements.

The practical problems involved in listing and pricing the various drugs, medicines and appliances and in calculating payments to chemists are very formidable. Millions of prescriptions will have to be priced and paid for each year. My Department have been involved in practical studies on the best methods of arranging for this and in this respect I would like to acknowledge assistance which we have obtained from the authorities in Belfast, Edinburgh and London who are responsible for operating similar arrangements. The initial preparations for this part of the service are being put in train in anticipation of the legislation, because the date of the commencement of the new general medical service will largely depend on the date on which these arrangements can come into effect. It cannot, I estimate, be earlier than the middle of 1970.

These major changes will, of course, relate only to general medical services for what we now call the lower income group, or what is defined in the Bill as "persons with full eligibility." For others, family doctor services will continue to be arranged privately. So will the purchase of drugs and medicines in normal circumstances. However, section 57 (2) introduces an important provision to safeguard the middle income group—in the Bill defined as "persons with limited eligibility"—against having to meet, unaided high expenditure on drugs and medicines. Much is done at present in this respect by the operation of the "hardship clauses" but I think the scheme under the new Bill will be better. It will be clearly spelled out that expenditure by a person with limited eligibility over a specified amount in a period of, say, a month will be recoupable in whole or in part by the health board. The minimum amount will be specified by regulations and will not be determined until this new provision is coming into operation but it is intended that it will be a sum which a person in the middle income group could readily afford to pay himself. Two pounds a month might be an appropriate figure.

I intend that this scheme should be simple to operate and should be clearly understood by the public. It will mean that persons in the middle income group will know that they will not be expected to budget from their private resources for excessively high expenditure on drugs and medicines.

In addition to these general schemes, there is provision in section 57 (3) under which health boards will be authorised to arrange to supply drugs without charge for long-term diseases and disabilities in persons of all income groups. As the House is aware, such a scheme operates at present for diabetics. This scheme will be extended to other conditions, such as cystic fibrosis and phenylketonuria. For such conditions only rare households could afford the expense of the drugs and medicines required and it is right that an exception should be made here so that all income groups will benefit from this provision. To sum up on these provisions for the supply of drugs, medicines and appliances—the lower income group will get everything free through, I expect, chemists' shops; the middle-income group will be guaranteed against excessive expenditure and the higher income group will be assisted as respects long-term and expensive items. These changes, with the introduction of choice of doctor, will involve a considerable additional outlay of public money, which may be between £½ million and £1 million a year.

Part IV of the Bill, in codifying the provisions in the other health services proposes a number of other improvements and extensions. Section 43, dealing with the definition of "full eligibility" departs from the old public assistance terminology under which "persons unable by their own industry or other lawful means" to make private arrangements for medical care were expressed as being eligible for the services. This formula has been dropped in favour of more modern terminology and it is made clear that only the means of a husband and wife as well as a person's own means will be taken into account in deciding whether or not he has full eligibility. Furthermore, there is provision in section 43 (3) under which regulations can be made specifying classes of persons who will automatically be regarded as coming within this category. This will lead to general uniformity in decisions on eligibility and, as the regulations will be public documents, it will mean that in future the standards for assessing eligibility will be known. However, it should not be taken that this definition of classes to be included among those with full eligibility can be all-inclusive. Because of varying circumstances, particularly in the agricultural community, it is necessary that the formula should retain considerable flexibility.

Section 45 contains a new right of appeal on all decisions relating to eligibility. There is no appeal at present on the question of issuing medical cards and the appeal in relation to inclusion in the middle income group is only of a limited nature.

The only major change in Chapter II of this Part, dealing with hospital services, is related to the eligibility of children for these services. At present, children of persons in the lower or middle income group are entitled to hospital services but children of those in the upper income group are entitled only in respect of defects discovered at school health examinations in national schools. This leads to an artificial distinction. Many higher income group children do not attend national schools and, even in the case of those who do, it is often purely fortuitous that it is at a school health examination a defect is discovered. The Bill will terminate this anomalous position, but will compensate parents in the upper income group by making in-patient services available for their children for permanent or long-term diseases and disabilities no matter where discovered. The most important of these would be mental handicap. As most upper income group people are covered by Voluntary Health Insurance, the loss of the right to free treatment on the grounds of discovery at school health examinations should be of no serious consequence to them, particularly in the light of the concession made for long-term conditions, which might not be fully covered by the voluntary health scheme. These changes in eligibility are, in general, on the lines of recommendations in the Report on the Child Health Services published last August.

Where in-patient hospital services are concerned there is at present a definite statutory provision under which charges up to 10/- a day may be made on persons in the middle income group. This is being replaced by section 51 which contains power to impose charges by regulations. Policy in the exercise of this power can be determined from time to time and consideration given as to whether the present charges should be retained in their existing form, or modified, or dropped. This issue could be affected by a future decision on the question of introducing a scheme of contributions by the middle income group for the services to which they are entitled.

In the case of out-patient services the Bill proposes to drop the existing charges for those services and to make the services available for all defects discovered at health examinations in pre-school as well as school children, as at present. Again, these changes accord generally with the Report on the Child Health Services.

The hospital services, are, of course, by far the most expensive sector of the health services. I think that the present pattern of eligibility is generally satisfactory and, having regard to the existence of the voluntary health insurance scheme, there is no substantial pressure for extending these services to a wider group of the population. Accordingly, section 44 re-states the present definition of persons entitled to these services. It will be noted, however, that under section 44 (3) there will be power for the Minister by regulations—which will be subject to the consent of both Houses of the Oireachtas—to change the definition of eligibility. This power could be used to make allowances from time to time for changes in the value of money or it could be used to change the general formula for eligibility. A suggestion in this respect was made in a Parliamentary Question by Deputy Donegan on 13 July, 1967, to the effect that the standard of eligibility for the services should be different for single people, married people and married people with dependants. While the Government have made no determination of policy in this respect, I would draw the attention of the House to the fact that a change of this kind could readily be made under this section, without of course necessarily charging the total number eligible for the services.

The provisions in sections 60 to 64 of the Bill relating to the services for mothers and children also have regard to the report to which I have referred earlier. An important change from the present law is proposed in section 64 (1) under which an examination service for pre-school children will be arranged. The present law limits this to clinics and health centres operated by the health authorities. By referring to "other prescribed places" in the new section, we leave the way open to bring the family doctors into this service. This was recommended for rural areas by the Report on the Child Health Services and, indeed, there is some feeling in the medical profession that family doctors in urban areas too should play a part in this service.

Section 62 takes into account the change in the value of money since the maternity cash grant was first fixed at £4 in 1953. This grant will be increased to £8 and a further concession is made whereby a double grant will be paid where there are twins, a treble grant for triplets and pro rata for any other multiple births.

Another change of some importance is contained in section 67, under which, in assessing if a person is eligible for a disabled person's — maintenance — allowance, only the person's own means and those of a husband or wife will in future be taken into account. Under the existing law, regard is had to the means of sons, daughters, and parents and of any brothers or sisters normally resident with the person.

While I dealt at some length earlier with the changes in the general medical services, my comments on the other provisions in the Bill on services have been brief, but the points to which I referred and, no doubt, many other aspects of the sections in this Part of the Bill will come up for discussion at Committee Stage. I will welcome views from all sides of the House on the details of these provisions at that time and may I sincerely say that I hope because the principles behind these provisions may not be in tune with the political philosophies of all Members of the House, that this will not prevent them participating in fruitful discussion on those details?

I would like now to revert to the earlier Part of the Bill, on the administration and financing of the health services. I hope that the general purpose is clear from the Bill and the explanatory memorandum circulated with it. The intention is to transfer the administration of all the health services to the new health boards. The membership of these would be made up of representatives of the local authorities in the area concerned, persons elected by the medical and other professions and persons appointed by the Minister. The boards would thus, in the words of the White Paper "represent a partnership between local government, central government and the vocational organisation". The arguments for making this change were given in the White Paper and were derived from two separate considerations. First, it was clear in 1966, and has been made more clear since by the Fitzgerald Report on the Hospital Services that, for those services, the county is too small as a unit. A much more effective service can be provided by grouping a number of counties for the administration of hospitals.

A modern hospital service is an extremely costly and complex undertaking. It requires not only a great deal of money but a large number of expert medical, technological and nursing staff of whom there is a short supply. In order to ensure that these expert staffs can work effectively it requires, too, that it should be based on large hospitals and large units of population. Obviously, in a country with our demographic pattern, you cannot realistically expect to be able to base this sort of service on every county. If then, as proposed by the Fitzgerald Report, our main general hospitals are to be located at a smaller number of centres, each catering for a number of counties, it follows that the administration of the service should also be based on groups of counties. The health boards will ensure that all counties participating in the service will have a say in its administration. They will also provide a means whereby persons, other than local authority representatives, with valuable knowledge or experience can be brought on to the boards.

The case for grouping counties is not as clear, of course, for other services and, indeed for some of them, such as the child health service, one could well argue that the county remains a suitable unit of administration. However, the White Paper concluded that the main advantage lay in having all the health services within an area under a single body and that if health boards as proposed were to be set up, they should have comprehensive responsibility for all the services.

I should mention that our views on this particular point have been confirmed by certain developments in Britain since the White Paper was published. In two green papers—that is documents putting out ideas for preliminary discussion—one for England and Wales and another for Scotland, proposals were put forward for a system of comprehensive health boards like those proposed in the Bill to replace the present divided system of administration in those countries. In general the idea of unified administration has been welcomed there and it looks quite likely that the next few years will see legislation in Britain for the establishment of health boards rather like those which we are now discussing.

The second reason for the White Paper's advocacy of a change to this form of administration lay in the fact of the State's increasing financial commitment towards the health services. The Government, by the White Paper committed themselves to acceptance that the cost of specific further extensions of the services—such as that in the general medical service as set out in the Bill—should not be met in any proportion by the local rates and, indeed, since the White Paper was published the proportion of health expenditure met by the State has increased substantially. This is another reason for the proposal for the transfer of administration to the health boards on the lines proposed.

The health boards will be bodies outside the ordinary Local Government system. The Bill proposes that the number of these boards and the area to be administered by each will be determined by regulations. In accordance with section 4, the Minister is required to consult the relevant local authorities before making such regulations and the regulations must be submitted in draft for approval to each House of the Oireachtas before being made. This means that there will, after the enactment of the Bill, be adequate opportunity for the local authorities, and later for this House, to consider the details of the scheme. It also means, of course, that I am not in a position to give any firm indication to the House now on what the detailed pattern will be. My Department have been studying the issue and, provisionally, I have in mind that the number of these boards should be about eight and that, as far as possible, the functional area of each will consist of a number of whole counties. Furthermore, it will be appreciated that in designing the regions I will have regard to regions for other purposes, and particularly those for planning and development.

Naturally, only a proportion of the members of each county council or other local authority concerned can be appointed to each health board. It is proposed, however, by section 7 to associate other members of the local authorities with the work of the boards by establishing local advisory committees for each county or other appropriate unit. These committees will primarily be there to advise on the provision of health services in their own areas but the board will have authority to delegate functions to them if that should appear appropriate.

Sections 12 to 23 of the Bill deal with officers and servants of health boards. These provisions draw much on the law on officers and servants in the Local Government Acts but there are some significant distinctions. The most important of these is that the statutory office of chief executive officer to a health board will not be analogous to that of a county manager. The latter performs all functions for a local authority except specified functions reserved to the elected members: the chief executive officer, under section 16 of the Bill will perform his duties on behalf of the board and in accordance with its decisions and directions— except as regards certain things in which he is specifically given functions by the Bill. These will be mainly decisions on individual applications for services and on the control of officers.

It has been said to me that there will be little practical difference between the operation of this provision and the normal relations between a county manager and the members of his council. That may be so, because a good manager will always act in concert with his council and without stressing his own sovereignty but I nevertheless think that the different legal status of the members of a health board vis-àvis the board's chief executive officer and other officers will be significant in giving considerably more weight to the authority of the members.

I should mention that I have received representations from the medical profession that each chief executive officer should be a doctor. I cannot accept this, as the primary qualifications for this office must lie in administration, but should a doctor succeed in competition in qualifying in this respect, I would be glad to see him becoming a chief executive officer. This is a point on which I would be particularly interested to hear the views of other Members of the House.

There is an interesting departure from Local Government law and practice in sections 22 and 23. Local Government officers are subject to discipline by the manager and to removal from office on disciplinary grounds by the Minister. Under the Bill, it is intended that the Minister will not be involved initially in disciplinary cases affecting officers of health boards, other than the chief executive officer. The investigation of a proposal to remove an officer on disciplinary grounds would be in the hands of a special committee appointed under section 23 and the Minister would become involved only on an appeal. This proposal is in accord with the general aim of devolving detailed functions from the Minister and his Department as far as practicable.

May I now turn to section 40 of the Bill, dealing with bodies for the co-ordination and development of hospital services which should be looked at in conjunction with the earlier proposals on health boards. This section in some degree reflects the thinking on administration of hospitals in the Fitzgerald Report. That report advocated a separate system of hospital administration in which there would be a central body to be known as the Consultants Establishment Board dealing with the control of specialties, three regional hospital boards and, under them a number of hospital management committees. This completely separate system of hospital administration is not acceptable, for reasons which I have outlined above and because of the administrative duplication to which it might give rise.

However, certain features of these recommendations of the Fitzgerald Report have been embodied in the Bill. While the basic administration of hospitals will be in the hands of the new health boards and, for the voluntary hospitals in the hands of their boards of management, the idea of a central co-ordinating body and three regional hospital boards is incorporated in section 40. The central body will be known as Comhairle na nOispidéal and its main function will lie in advising on the regulation of the number and type of consultant appointments in hospitals. It will also be concerned in the qualifications for such appointments and will have general advisory functions. At least half of the members of this body will be hospital consultants.

The three regional hospital boards based on Dublin, Cork and Galway will have the different function of being concerned in the general organisation and development of hospital services in the health board hospitals and the voluntary hospitals participating in the services within the regions. Each regional hospital board will draw one-half of its members from the health boards within its region and the other half will be appointed by the Minister after appropriate consultations.

Some critics have seen in the provisions relating to the administration of the hospital services an attempt by me, by the State, to end the traditional independence of the voluntary hospital system. I have already stated that that is not my intention. I repeat that now. We owe a great deal to our voluntary hospitals, to the religious communities and lay boards associated with them for the standards of hospital care and medical teaching which they have established and maintained during their long history. It would not only be thankless but foolish for me if I were to attempt to end their independent status and put them all in a bureaucratic strait-jacket. But having said that, and emphasised that, I know that I can expect those voluntary hospitals participating in the public services to accept certain restrictions and conditions in the interests of the hospital system as a whole.

It is not necessary for me to labour the fact that the cost of running our hospital service is by far the largest element in the soaring cost of the health services. The administrative machinery I am now proposing for the hospitals is aimed at securing a more efficient and effective service and a better return for the money we are spending. Obviously this must necessarily involve a willingness on the part of all hospital authorities to accept a planned and rational approach towards the future organisation and development of the service.

Section 40 represents a compromise between what the hospital consultants might regard as the best form of administration for the hospital services and what the Government think public representatives at national and local level would accept for this purpose. Like most compromises, it will not fully satisfy everybody. I have not yet got in detail the views of the organisations concerned on the actual text of the section but, when I have these views and have considered them I may wish to suggest some modifications in the section on Committee Stage.

It became clear to us in framing the new form of administration that, with the establishment of these bodies and the general transfer of administration to the health boards, the Hospital Commission would no longer have a sufficient function to perform. Accordingly, it was decided to include provision for the eventual dissolution of the commission. The Hospitals Commission was established in 1933 mainly for the purpose of advising on the spending of money derived from the Hospital Sweepstakes. Conditions were, of course, much different then from what they are now. During its existence the commission has performed a very useful function and in recent years it has become involved, by agreement with the voluntary hospitals, in general work designed towards encouraging efficiency and economy in those hospitals. The chairman of the Commission and its members and staff are to be complimented on the manner in which they have done this work. That it is now proposed, because of the evolution of administration, to dissolve the commission reflects no discredit on them.

The establishment of health boards and of the new hospital bodies will cause somewhat of an upheaval in health administration. As well as the Hospitals Commission, the Dublin, Cork, Limerick and Waterford Health Authorities, the seven joint mental health boards and the Western Health Institutions Boards will be dissolved. In all, as against the 12 or so new bodies being set up, 13 will disappear. There is also provision for the transfer of health staffs from county councils. These matters are dealt with in sections 33 and 36 of the Bill. These sections will affect several classes of officers and many individuals. The next of the Bill has been sent for comment to organisations representing the various categories of health staffs. I would like at this stage to say that their views on any difficulties which they expect on the working of these provisions will be received most sympathetically by me, both before the enactment of the Bill and later. If necessary, I will be prepared to bring in amendments in this respect on Committee Stage.

Sections 26 to 32 of the Bill contain the provisions on the financing of the new health boards. Their accounts will be kept in a prescribed form, they will be audited by Local Government auditors and the certified abstracts of accounts will be presented to the Minister and to the local authorities concerned. The Minister will present copies to the Houses of the Oireachtas. Budgetary control of health boards will be exercised under sections 29 and 30 as, under these sections, the authorised estimates of health boards will be binding on them and may be departed from only with the Minister's consent. The chief executive officer of the health board will be given a function, similar to that which the accounting officer of a Government Department has, to ensure that the financial controls are properly observed.

The sources of finance for the health boards are specified in sections 31 and 32. The boards will be financed mainly by way of State grants and local contributions. The State grants will meet one-half of the total running expenditure and a further proportion as determined from time to time. The local contributions will meet the balance. The contributions for individual local authorities will be determined by regulations made by the Minister for Local Government, which will be presented to the Houses of the Oireachtas.

The effect of these provisions, of course, is that there will be no such thing as a statutory "freeze" on the amount of the local contributions, but I should point out that the section is framed so that, should the Government of the day decide in future that such a freeze was desirable, it could be provided for. I would personally not think it appropriate that future Governments should be firmly committed by the Bill in any way in this respect. The decision on this is something which has to be taken from time to time in the light of the general financial circumstances—central and local. Accordingly, section 31 in its present form seems to me to be more appropriate than one setting out a more rigid financial basis for the services.

The Bill contains several other useful miscellaneous provisions. By the transfer, under section 42, of the administration of the Dundrum Central Mental Hospital to the appropriate health board we should achieve a much better use of that institution as it should greatly benefit by co-ordination with other psychiatric hospitals in the area. A simple procedure for amendment of hospitals charters or private Acts is proposed by section 73: this will enable the boards of governors of hospitals to avoid the expense of private Acts. Confusion relating to health authorities' powers in the removal of bodies of dead persons found in their areas, which has led to some distasteful incidents in the past, should be removed by section 74. Finally, by the provisions of this Bill, certain repeals of the Mental Treatment Act, 1945, and the proposals for the adaptation of those Acts under section 78, the remnants of the distinctive legal provisions on the provision of services for the mentally ill will be removed, so that the same law—as contained in this Bill—will apply in relation to eligibility for those services and the provision of those services as applies to other hospital services. The only part of the mental treatment code which will remain will be those necessary provisions governing the procedures for the admission of patients to mental hospitals and the retention of patients in those hospitals. I should hope that, in the future, a separate Bill will repeal these remnants of the Mental Treatment Code and replace them by a simplified procedure. For the moment, I would point out that the Health Bill takes what might be called the penultimate step in removing the distinctions which have traditionally existed for the care of the mentally ill.

This Bill is a highly technical document in its provisions on the administration of services, the financing of services and eligibility for health services but, basically we are discussing on it what the public authorities should do for our people as a whole in the prevention and cure of disease and in caring for the ill, the infirm and the aged. I present the Bill to the House as offering what the Government consider the most rational solution to a number of the problems which arise. I put it to the House with no apology for its not being something else, such as a Bill for the introduction of a comprehensive national health service: we do not think that the people need that or want that. I hope the House will accept the Bill as offering the most reasonable vehicle for the future development of our health services in accordance with the general philosophy and traditions which have served this country well in the past.

I move amendment No. 1:

To delete all words after "That" and substitute: "Dáil Éireann refuses to give a Second Reading to the Bill on the grounds that:

(a) it fails to provide a comprehensive health service available to everybody based upon insurance principles;

(b) it retains the injustice of financing half of the cost of health services out of local rates; and

(c) it gives at the expense of local authorities and hospital administrators excessive powers to central government."

I move this amendment on behalf of the Fine Gael Party. I move it in a spirit of challenge and defiance, of public challenge and defiance of the Minister and his Fianna Fáil Government, who presume to say once again, after more than a decade of debate has proved otherwise to the country, that medical expenses do not cause hardship to our people.

I move the amendment in a spirit of restating once again the Fine Gael philosophy of, and commitment to, the establishment in our midst of a just society, that is a society which so arranges its affairs that people with means, people with adequate income, and people of wealth contribute, when it is not difficult for them to do so, towards the insurance fund which ensures that no one is deprived of or is delayed in obtaining medical and hospital attention when necessary.

We move our amendment in the conviction, which is recognised by every public representative in this country, that the rates are not the proper system for providing finances for the health services, a recognition which was spelled out in black and white in the Government's White Paper of 1966, which acknowledged that the rates were not the proper system for the financing of what they call further improvements or extensions of health services.

Which remains Government policy.

Government policy may be one thing, but the legislation is obviously entirely another.

That is not so.

At this time we have the principal local authority in Ireland in a state of disintegration because, after a decade of reluctance so to do, the Labour Party have at last sided with Fine Gael in refusing to be a party to an unjust system, to an unjust law, to an unjust extraction of money from the people. In the atmosphere of that state of crisis, the State, as represented by the Minister for Health for the time being and the Government for the time being, proposes to project into the future this injustice which has been denounced by every local authority throughout the length and breadth of this land, by Fianna Fáil, Fine Gael and Labour councillors alike; proposes to project, once again into the future, for later generations to suffer under, the system in which the State accepts responsibility for only one-half of the cost of the health services.

The Minister says it is still the policy of the Government not to charge the rates with future extensions or improvements in health services. The Bill says otherwise. The Bill says in section 31 that half the cost of the health services, past, present and future, will be paid by the State. It makes allowance for a "generous" Government contributing more than half. The Minister in his introductory statement said that provision was being made in this Bill so that at any time any Government could provide that their obligation would not exceed half of the cost, the half cost which is provided in section 31 and which we in Fine Gael entirely reject as unworthy, as unchristian, as contemptible, as insufficient.

I shall not embarrass the Minister by thanking him for this miserable measure. I know that Seán Flanagan, Deputy from Mayo, my one time professional colleague, an individual of generous disposition towards his neighbours, is not satisfied with this measure. I know that he sought a great deal more from the Government. We know he has not spent idly the years since he became Minister; we know from his own utterances to the Dublin Health Authority, of which I have the privilege to be a member, from his own statements made in this House and elsewhere, that he wanted to do a great deal more. Therefore, I shall express my sympathy with him that he has to come before this House and endeavour to justify such a mean, small-minded, begrudging and niggardly Health Bill as we are asked to approve. Banquo wrote the White Paper upon which this is based. It seems to me that Banquo walks tonight. A very sad ghost must walk and I believe the Minister in his heart of hearts walks with him.

This Bill is the great let-down. It is the great denial of all that our people have been looking for. This Bill leaves what is worst in our medical services unchanged. This Bill does little that is good. This Bill does much that is harmful. This Bill is evasive when it should be concrete. This Bill is a mere shadow of what our health services should be. It strikes us in the Fine Gael Party that this Bill is a lazy and cute method of replacing positive proposals which could be criticised with a confusion of powers to make regulations, the extent, the worth, the application, of which we know absolutely nothing.

The essentials of a good health service should be the provision of medical aid at all levels when required and the availability of all such medical aid with the minimum of difficulties, the creation of a system where such health services would be paid for out of income at a time when it would not be difficult to provide such payment. A good health service would ensure that one would get medical attention as of right without having to prove in a time of need that one is a pauper; without having to prove in a time of need that one is destitute; without having to prove to bureaucrats or to politicians at a time of need that one is suffering from some serious and costly or malignant disease.

The essentials of a good health service require that people will be free from worry in so far as it is humanly possible to provide such freedom. The essentials of a good health service require that such a service should be free from all complications which are unnecessary. The Fine Gael Criticism of this contemptible and utterly inadequate Health Bill arises because of the fact that, as in the past, medical attention in the future will not be obtainable free of payment at the time of need without proof of one's poverty; without disclosure of one's means and without, in many cases, crawthumping to politicians. Our objection to this miserable measure arises because we are satisfied from the multitude of restrictions in the Bill and the greater number of yet undisclosed restrictions that the attention of a doctor and the care of a hospital will not be available immediately when required and there will be so many restrictions imposed that many people will, as they have done in the past, postpone getting medical attention until their impairment reaches such a stage that they have no alternative. Because medical attention will be postponed for so long the cost of treatment and the cost of institutional care will be thereby multiplied.

We, in Fine Gael, condemn this Bill because it does not arrange the finances of our society and of our income-earning community in such a way that people are enabled, without hardship, to make a small payment all the time, thereby ensuring that, when services are necessary, they can call upon those services without having to make payment at a time when their income is cut. We, in Fine Gael, condemn this measure because we are satisfied it will ensure the continuation of a system under which people will continue to worry, not only about their sickness or disability but about the cost of trying to repair that sickness or disability.

We in Fine Gael, condemn this measure because, rather than trying to make our medical services simpler, as we, in Fine Gael, have been advocating down through the years, and as the Select Committee of this Dáil advocated, this Bill proposes to make the system more complicated than ever. The Bill is silent when it should speak out clearly with regard to entitlement and, where it does speak out, specifying entitlement, in the next subsection it negatives all that contained in the provision with regard to entitlement.

I refer specifically to section 44. Section 44 presumes to spell out those who are to be entitled to what is described as limited eligibility. It describes as people entitled to limited eligibility persons insured under the Social Welfare Act, 1952; adult persons whose yearly means are less than £1,200; adult persons whose yearly means are, in the opinion of the chief executive officer of the appropriate health board, derived wholly or mainly from farming, if the rateable valuation of the farm or farms concerned (including the buildings thereon) is not more than £60; dependants of persons referred to in paragraphs (a), (b) and (c). When one reads on one finds that, within the same section, the Minister can wipe out section 44. He can make a regulation at any time depriving from benefit many of the people mentioned in the section. It may be that he may extend its provisions. We would have no objection if he did extend them, but what we regard as rather Gilbertian is the writing into this section in a Bill of such great moment specific entitlement and then, in the self-same section, saying we can wipe out all that, allowing the Minister to vary it at any time in such manner as he may wish, subject, of course, to a resolution approving the draft, if passed by this House.

One wonders why the Minister has gone to the bother of spelling out in the Bill entitlement to services based upon figures fixed three and a half years ago. This ceiling of £1,200 was fixed in November, 1965. It was extended to health services on All Fools' Day in April, 1966. Three years later, after three substantial moves forward in earnings, the Minister proposes to fix as a ceiling of entitlement to benefits under the Act the ceiling which was regarded as suitable three and a half years ago. Either it is applicable or it is not and, if at the time of the drafting of this measure it was thought to be unsuitable, then why write into the Bill a ceiling which is acknowledged to be three and a half years old?

The White Paper of 1966, which was published after almost five years deliberation on health services conducted by the Select Committee of this House, acknowledged that rates were not a suitable form for the financing of health services. It acknowledged that any extensions or improvements should not be financed in any part from the rates. Yet the Government which published that White Paper now proposes in this legislation to go back on what it has published, to go back on its own acknowledgement that what it was doing was wrong, and it proposes to perpetrate a gross injustice because it proposes certain extensions—not substantial, God knows—and it proposes that the statutory obligation on the State for those extensions will not exceed any more than 50 per cent. To us, in Fine Gael, that is a contradiction no Government can be allowed to ignore and, because of that, we are obliged to vote against this Second Stage of this Bill. We believe this goes to the very root of our health services and it is because of the Government's failure to live up to its own admission of wrong that we now find ourselves obliged to repudiate the principles upon which health policy is based in this Bill.

We, in Fine Gael, have pronounced our conviction that it is wrong to charge people for health services when their incomes are substantially cut through illness, disability or unemployment. We consider it is wrong to continue a system making a charge of any kind on insured workers in respect of their hospitalisation. We have asserted, and we assert once more, our conviction that it is wrong to call upon people to make a payment of as much as 10s per day in respect of their maintenance in hospital. The total income to our health services under the heading of in-patient charges amounts to no more than 1/60th of total health costs; the 1/60th part of total health costs are recovered in the form of 10s or smaller amounts per day in respect of in-patient treatment and maintenance. The mere preservation of this worries sick people, worries their families, costs an immense amount to administer and I suspect that, if the net cost were taken into account, you would find that figure of 1/60th would be down to 1/100th or thereabouts.

Is there any point in maintaining such a system when it caters for such an insignificant part of the total service? Fine Gael think not. If this were to be transferred from the existing system, from the present unsatisfactory system of 50 per cent contribution from the State and 50 per cent contribution from the local authorities, you would barely see a reflection of an increased cost. Therefore, in the Fine Gael mind, it is unwarranted to continue to operate such a system which causes pain to the sick, to the suffering and to their families and which confers practically no worthwhile benefit on the community. We are glad that the Government have finally come around to abolishing the miserable 7/6d or 2/6d charge in respect of outpatient treatment or X-ray. There was never any worthwhile justification for these things. For some years past the total overall contribution to health services from such miserable sums was no more than 1/600th part of health costs.

Since the publication of the White Paper and, indeed, long before that, we have been complaining about the delay on the part of the Government in abolishing these utterly ridiculous charges which cost more to collect than they ever confer in benefit on the health service generally. If the State, the Minister and this Fianna Fáil Government are abolishing these charges one can assume from the rest of the Government's Bill that it is not due to generosity on their part but to a realisation that the collecting of these charges costs far more than it is worth. We in Fine Gael condemn this measure because it proposes to preserve the limit of 30 per cent of our population for entitlement to free medical services at all levels. We consider that it is possible for our community, as it has been possible for all communities in Europe with the exception of the Laps in Finland, to organise a health service which would entitle everybody, as of right, to get medical services without charge at a time of need. We have not ever heard from the present Minister for Health, from his predecessors in office or from any member of the Fianna Fáil Government any reason why we in Ireland cannot do the same as the rest of Europe. Even countries notoriously behind in such legislation as Spain and Portugal are able to do more for their sick and infirm than we can do in this country, although we profess hypocritically to be ahead of Spain and Portugal.

We reject this Bill because it makes no effort to extend the percentage of our people entitled to free medical services. We say this in full knowledge of the reservation which some members of the medical profession have expressed regarding an extension of the number of our people who would be entitled to free general practitioner and institutional services.

We in Ireland have every reason to be grateful to our doctors. We have one of the best medical professions in the world. They have achieved great things for our people and they have dedicated their services to our people far beyond the call of duty. Notwithstanding our limited means, our medical men have achieved and have reached wonderful new frontiers in medical science. They have devoted themselves—often without remuneration—to the assistance of the least privileged in our community. I think we can say, as regards the future, that they will do as they have done in the past.

If the medical profession, at the recent conference in Killarney, expressed some reservations regarding extensions in the number of people entitled to medical assistance without charge, we must view that expression in the light of the present unsatisfactory position of what is now proposed. We must accept that doctors are entitled to receive adequate remuneration for their services. No trade unionist, no worker, no person who works hard and who expects to receive fair remuneration for his services, will begrudge doctors receiving adequate remuneration for their services. The more skilled people will realise the justice of the claim for doctors to be paid according to their skill. However, our medical profession has expressed reservations regarding the extension of the number of people entitled to free treatment because, under the system as it now exists and under the system as proposed, what would happen is that it would increase the case load of overworked dispensary and public service doctors who would receive no additional remuneration for their increased responsibilities and their increased work and, at the same time, paying patients and income properly deserved would be taken away from doctors operating in the private sector.

We in Fine Gael are convinced that we shall continue to suffer here resentment on the part of the medical profession, caution on the part of the medical profession, fears on the part of the medical profession so long as we try to preserve here a system under which we confine entitlement to medical services without charge to only 30 per cent of our population. If we did what every other progressive country in the world has done or is trying to do, if we opened up entitlement to medical services to all our people and the operation of them to all our doctors without reservation, we should then remove much of the fears and much of the reservations and much of the understandable caution on the part of the medical profession.

The fact that it is now over three years since the infamous White Paper was published and that in the intervening three years the Minister has been unable to negotiate any acceptable system of remuneration of the medical profession is a terrible condemnation of the Minister and of his proposals. It is unfair, I think, to expect the medical profession to work, as our society has expected them to work in the past, 60, 70 and 80 hours a week, and more, without compensating them for working such extraordinary hours. Not only is it unfair: it is impossible for them to do it. They are not doing it in other countries. Our medical graduates are acceptable in other countries and they will not suffer a system here which will make such impossible demands upon them. It is unreasonable to propose to the medical profession a scheme of remuneration which says to them that they are to accept a flat rate up to 10 p.m. and improved rates only after that, when there is no other vocation, profession or occupation or employment which would accept such terms. This may be an argument which, translated into experience in the future, will result in even greater health costs than those we have previously experienced; but if this be so we must accept this as an obligation.

We cannot expect our doctors to be our slaves and servants evermore without adequate remuneration and, therefore, while in common with most of our people I resent the recent resolution at the Killarney Conference of the Irish Medical Association refusing to work any system which would extend entitlement to health services, I say, with my colleagues in Fine Gael, that you must accept that doctors are entitled to fair remuneration for their services and if you would only approach our health services in the right way you would succeed in removing much of their worries and concern.

Indeed, I speak from my own experience and that of other Members of the House, when I say that most doctors hardly know the value of money; their last concern at any time is about payment or rendering their accounts to their patients; but they have an obligation to themselves and to their families to ensure they receive adequate remuneration for the services they are expected to perform. They have performed near-miracles in the past for an inadequate income and if now, at this stage, at a time of seeming change, they assert their rights, they are entitled to assert them.

We in Fine Gael are opposed to the new proposal in this Bill to apply a restriction on entitlement to free medical services in respect of defects ascertained in children in the course of school examinations. As I understand it, it is proposed that in the future people who earn in excess of £1,200 a year will be called upon to pay for medical attention for their children. Now, to anybody earning less than £1,200, it probably seems that it would not be any great hardship on parents of children who are in the £1,200-plus bracket to pay for the medical care of their children, but we ought to call a halt here, for a moment to consider what the facts are. One-tenth of our people are already earning in excess of £1,200 a year; within three years from now it is expected that one-fifth of our people will be earning in excess of £1,200 a year. This points to the fallacy of applying, in a Bill of this nature, a ceiling of £1,200 a year. If people are earning in excess of that figure the probability is that they are also purchasing and paying for the houses in which they are living and that they are also meeting certain other unchangeable and continuing obligations. We in Fine Gael believe it is unjust to say to such people that in future they should be deprived of services which they enjoyed heretofore because their children are entitled to just as much as the children of the statutorily acknowledged poor and the children of the statutorily acknowledged rich. All children should be treated alike and even the Minister will acknowledge that that should be so. But the Bill proposes a change and proposes a change at a time when we know, as a matter of almost certain fact, that anything from one-fifth to one-quarter of our people will be deprived of free medical aid for their children within a few years because of the inevitability of increases in income. This is a retrograde step. This is a measure which we regard as unjust by any standard. But the degree of injustice is multiplied when you realise that such people are to be asked to pay even more in the future than they have in the past, through rates, for the provision of services from which because of this measure they are to be entirely excluded.

We, in Fine Gael, express disappointment that the Minister in this measure is not taking steps, which in this House in reply to Parliamentary Questions he has acknowledged are justified, in relation to the treatment of people in hospital or elsewhere in respect of impairment suffered in the course of accidents where a third party is responsible for the injury. It is beyond reason why we should not provide in this Health Bill a section whereby in the event of a person suffering injury in an accident caused on the road, in industry or elsewhere, requiring hospitalisation we could recover the costs of hospitalisation from the party responsible for the accident or the injury.

The public generally do not realise just how stupid we are as a society. If a person with a blue card is knocked down on the road that person under our existing system is treated in hospital without charge. We will just take a particular case. The cost of the hospitalisation of that person might amount to £120 but we make no effort to recover the cost of that hospitalisation from the person whose negligence pushed the person into hospital in the first instance, because our courts have ruled that it is not permissible for a person who is the holder of a medical card to recover the cost of hospitalisation against the guilty party. Therefore, the guilty party or his insurance company goes scot free. What is the result? The result is that the ratepayers pay 50 per cent of the cost and the taxpayers pay the other 50 per cent. All that is necessary is a simple section in this Bill to provide that, where a person is hospitalised as a result of the negligence of another person, the cost of such hospitalisation and medical treatment would be recoverable against the person whose negligence caused the injury. This would relieve the ratepayers and the taxpayers of the cost of providing for such a person.

I cannot find any sound reason for failing to provide such a simple provision in this legislation or elsewhere. The time has long since gone when we should tolerate the Minister for Health saying that this is the matter for a Road Traffic Bill or tolerate the Minister for Local Government saying it is a matter for a Health Bill. I think it is primarily a matter for a Health Bill. We should be endeavouring to remove from the ratepayer and taxpayer the responsibility for the cost of maintaining a person in a hospital or the cost of providing medical treatment for a person injured as a result of the negligence of another person, be it in the course of a road traffic accident, an industrial accident or any kind of accident where the injury can be attributed to the negligence of another person.

I have been endeavouring here and elsewhere to obtain statistics to show the number of people receiving medical care as a result of accidents, either in hospitals or from dispensary doctors or private practitioners, and it appears that such statistics are not readily available. I can think of one hospital in the Dublin Health Authority region which is on a major dual carriageway —I refer to Loughlinstown Hospital on the Bray Road—and, speaking from recollection, I think the position there is that up to 20 or 25 per cent of the cases in that hospital arise out of road traffic accidents. As the Minister, from his private practice as a solicitor will know, there is hardly any road traffic accident in which negligence cannot be attributed to one or both parties involved. Certainly, damages are recoverable in respect of pain and suffering in practically all road traffic accidents and it appears to me and to Fine Gael to be entirely wrong not to recover the cost of hospitalisation and medical treatment in such cases from the negligent party. If it could be recovered it would have a worthwhile impact in reducing the cost of health services. Therefore, whether the Minister does it or not, we in Fine Gael will be tabling an amendment on the next Stage providing that hospital and medical costs in the case of accidents which are attributable to the negligence of a third party should be recoverable from the negligent party.

This may have some effect in increasing insurance premiums on motor cars or in relation to other insurance but we believe it is justifiable because there is certainly no justification in maintaining a system which amounts to this: that if you are going to knock down somebody on the road you should be sure to knock down a medical card case because you will not then have to pay anything for medical treatment, but if you knock down somebody not entitled to free hospitalisation it will cost you or your insurers or your employers a great deal more. There is no justification for continuing such a system. It amazes us in Fine Gael, in relation to a measure which is supposed to make comprehensive changes in our health services, that steps have not been taken, particularly by a Minister who has legal experience, to bring about this much required reform.

I should like, personally, to express disappointment that the Minister has not taken the steps in this Bill that were promised to me many years ago by himself and his predecessor to reform the law in relation to the registration of births, deaths and marriages. This registration is at present performed by medical officers of health, but, as I have pointed out, in urban areas this means that the duty is performed by doctors who have no knowledge of the identity or activity of at least four-fifths of the people resorting to them for such registration. In the Dublin area no more than 18 per cent of the people are entitled to general medical services which means that no more than 18 per cent of them have occasion from time to time to resort to the local dispensary. Notwithstanding that, we continue to operate a system which requires that no birth, marriage or death will be registered unless necessary identifications and declarations are made to the local dispensary doctor who knows nothing about the accuracy of the declarations and still less about the identity of those appearing before him.

The result is—I do not know if the Minister personally has experienced this but many other Members of this House have, and so have others—that if there is a child born to a Dublin family the father or mother has to go to the local dispensary, there to join a queue of people seeking medical treatment and wait, perhaps a couple of hours, in order to make a declaration before a person who knows nothing about the facts that are declared. I cannot see why this measure would not be used to amend the system so as to allow such declarations to be made before any peace commissioner or commissioner for oaths and filed, without all this unnecessary waste of human time, in the Custom House or elsewhere. When we can make provision in this Bill, as we do, for the publication of notices in relation to rat and mice infestation we should be able to provide for the relief of human misery and agony and avoid the waste of human time and effort involved in the registration of births, marriages and deaths.

As regards the drafting of the Bill, may I say a word? We appreciate the publication of the accompanying Explanatory Memorandum. The Department of Justice, at least, have in recent years established the practice of writing into the margin of Bills references to the sections of existing Acts affected by the sections in the Bills being introduced. I urge on the Minister, if it is too late to do it in relation to this Bill, that in any future Bill produced by his Department, in the margin of the Green Bill, reference would be made to the sections of existing Acts affected by sections in the Bill. That does help. I appreciate that in the text there are some references to existing Acts but this is not exhaustive. Absence of such references makes the reading of a Bill and its interpretation increasingly difficult.

May I also suggest to the Minister and his advisers that explanatory memoranda should be enumerated in a different way? It does not help in understanding a Bill to find the paragraphs in explanatory memoranda numbered in a different way from the sections contained in the Bill. There is no point in enumerating paragraphs in explanatory memoranda unless the enumeration is similar to that contained in the Bill itself. Taking page 3 of the Explanatory Memorandum you find that paragraph 11 refers to sections 17, 18 and 19 of the Bill. You find that paragraph 12 of the Memorandum refers to sections 20-23 of the Bill. It would be better to produce these explanatory memoranda in such a way that the section of the Bill is spelled out instead of enumerating the paragraph of the explanatory memorandum in a different way. I do not mention this by way of carping criticism but in the way, I hope, of helpful comment so as to ensure that explanatory memoranda will be more explanatory and more helpful in the future because that I understand to be the intention of the production of such documents.

If the State intended to contribute more in the future to the cost of health services there might be some justification for the proposals in the Bill to take from local authorities much of the powers which they at present have in relation to the administration of the health services but the Bill proposes to centralise authority in the hands of the Minister for Health and the Minister for Finance to boot. Indeed, the Minister for Local Government and the Minister for Justice are also mentioned in this Bill as people whose almighty imprimatur has to be obtained in future to many of the things that are now conducted quite successfully by local authorities and by local health authorities.

We, in Fine Gael, object in Opposition and we shall object in Government after the next general election to proposals which unnecessarily take from local level much of the powers which are at present most successfully operated by local authorities. If there are any improvements in this Bill they stem, not from the imagination of the Minister for Health or his advisers, but from the humanitarian activities of local politicians and local health authorities who have run ahead of the Minister and have provided services even where there was, if I may say so, doubtful legal validity for the provision of such services.

The Dublin Health Authority, for instance, has been providing assistance for meals-on-wheels, for the provision of home nursing and home services and for maintenance allowances for the infirm, the disabled, the blind and the aged far beyond what the Minister for Health recognised as being proper for them to do. The Dublin Health Authority of which I am proud to be a member and in which we in Fine Gael are the dominant Party, have insisted on doing these things in defiance of the law because we are concerned with the provision of these health services and not with what the law says. Rather, we are concerned with justice, reason and humanity. Not even a Fianna Fáil Minister for Health would dare to challenge our right to do these things because if he did he would carry the public odium attached to challenging our right to do so.

Unfortunately, these things have to be done entirely at the expense of the Dublin ratepayers so that in so far as the Dublin region is concerned, the State is not contributing, as it pretends to contribute, 54.7 per cent of the total health cost but is contributing only 46 per cent. Even the most anguished and the most impoverished Dublin ratepayer does not complain about the provision of many of the services which the Dublin Health Authority have been providing and which, for the first time, in this legislation are now being authorised by the State.

The Dublin Health Authority know that there are other ways by which these services could have been provided. There are many people now being maintained long-term in institutional hospitals who would never be there at the colossal public expense of £20 per week and upwards if we had had in time the sanity of providing proper home nursing and proper domiciliary nursing to maintain them in an adequate state of health in their own homes and in the community. We have in Ireland the greatest number of people per head of the population in institutions and this is because of the fact that we have a health service which is wrongly conceived.

The health service is basically an ambulance or an emergency service. Of the total cost we provide only 5 per cent to protect people from falling into serious ill health. We spend only 5 per cent on putting a fence around the cliff to stop people falling off and we spend the other 95 per cent in providing an ambulance service to pick up the injured, the maimed, and the sick at the bottom of the cliff and in transferring them to hospitals to restore them to the health from which they would never have diverted if we had provided a proper service to maintain them in their own homes and in the community.

We in Fine Gael are in absolute disagreement with Fianna Fáil in relation to the health services. We wish to provide a service which, by an increase of a mere 10 per cent in overall health costs, would reduce substantially the number of people in institutions and which would increase the amount of activity in which the general practitioner could engage to his own benefit. We want to see a service which would reduce the amount of frustrating expenditure in which we have to engage in the building of institutions which are unnecessary to the proper care of our people.

However, I shall return to the question of Part II of this Health Bill. The interesting thing is that in the famous 1966 White Paper the construction of the health services was relegated to the very last chapter of the paper but in this Bill which, of course, is little more than a general election fanfare, most of the sections are devoted to the construction of new authorities which will not of themselves give any benefit to the community.

The Minister proposes to abolish existing health authorities and to take powers from several local authorities which they now have in relation to health services. He proposes to replace these with boards whose membership shall consist of persons described as "persons appointed by the relevant local authorities", with "persons appointed by election by registered medical practitioners and by election by members of such ancillary professions" as he by regulations may specify. However, in relation to this, it is fair to point out that these boards will not be representative of local authorities and will not be representative of the ratepayers. In fact, they will not be representative of the taxpayers either.

There might be some justification in changing the system if the State were acknowledging in this Bill that it would accept more responsibility for the financing of health services but that is the very thing that the Minister is at great pains to avoid in the Bill. He is not going to accept responsibility for any more than 50 per cent of the cost of the service. He proposes to take from local authorities the powers which they now have. Persons appointed by the relevant local authorities to a health board are not to be less than half of the total membership, which means that they probably will not be getting any more than half anyway. The other members of the new health boards are to be appointed in the first instance by the Minister. They are not to be elected. One can very properly ask why the Minister is not proposing to allow the medical profession and "ancillary professions", by which I presume he means pharmacists and others, to elect their members to the first boards. Is it because the Minister fears he might not have control over them? I believe that is the reason. If the Minister was genuine in his intention to have those bodies democratically representative of the community and the profession he has had three years in which to conduct negotiations with the medical profession and ancillary professions to ensure that they would set up the necessary system of election for appointment to those boards.

What has the Minister done in the last three years? Nothing, absolutely nothing. He has done absolutely nothing to get those bodies interested in setting up the machinery for electing their own representatives to those boards. Whether it be this Government or any other Government which are in power in this country, it is fair to say at least a portion of the people appointed by the local authorities will be in sympathy with the Government of the day. Therefore, what this Bill is proposing to do is to set up in place of the existing health committees or local health authorities a system under which more than half of the representatives will be the creatures of the Minister, will be the creatures of the Government of the day, afraid to offer criticism, never with the guts to stand up against the Minister and always anxious to carry out his whims and fancies. One suspects that some of those appointees will be people promoted out of the Department of Health to facilitate promotions within that Department, which has never been slow to create bodies outside itself in order to facilitate promotions within the Department.

Those new boards are not provided for in this Bill. The number of them or the construction of them is not provided for in this Bill. Although we have had three years in which the Minister has had ample opportunity for discussion with the relevant local authorities in regard to the organisation to be provided in the future, there is no provision made for these boards in this Bill. It is not good enough to say that any regulation to set up the boards must be approved by Dáil Éireann and Seanad Éireann. The Minister and his advisers know it is not an infrequent experience that regulations are put on the Table of this House which are never properly examined because of the multitudinous pressures and distractions operating here. It is wrong to bring in a Bill in the closing hours of the Eighteenth Dáil to establish new health authorities and new health boards in this country without spelling out exactly the authorities, the powers, the regions and areas that these health authorities are to govern.

On section 5, I would ask the Minister a question which, as a lawyer, he will understand. Section 5 sets out the general provisions regarding health boards and states what the powers and liabilities of the boards shall be. Section 10 sets out the general provisions regarding the joint health boards. If you go to section 40, subsection (3) you will find bodies for the co-ordination and development of hospital services. There is a distinct difference between the provisions applying to the new health boards, the joint health boards and those other bodies. I should like to get some clarification as to why there is variation, as set out in this Bill, in the provisions applying to all those bodies.

I now want to refer to section 7, subsection (3) which provides for the membership of local committees which are to include members of the council of the county or county borough for the relevant area. It is not clear here that the members of those local committees will be members of the relevant health boards. While one would have a certain desire to see maximum local representation given, it might be undesirable to have people on local committees such as are envisaged in section 7 who would not be aware of the problems of the regional committee. It would be preferable to ensure that at least some members of the health boards would also be members of the local committee.

I should like to refer now to section 12. This provides that each new health board—I understood the Minister to say there will be eight of them—will have a chief executive officer. It is provided that before the establishment of a health board the Minister may request the Local Appointments Commission to select a person for appointment as chief executive officer. We would prefer to see that left entirely to the Local Appointments Commission. We resent the provisions under section 12, subsection (9) whereby the Minister may make a temporary appointment of a chief executive officer. We ask ourselves if this means that the Minister may choose, before the establishment of a health board, his own particular nominee, that this nominee may operate for some considerable period of time before the Local Appointments Commission are asked to make an appointment, thus giving the Minister's appointee preference when the pernament appointment arises.

We consider that to be objectionable and unnecessary and we would urge on the Minister that he would deprive himself of that power of temporary appointment. We believe it is perfectly feasible for the Minister to ask the Local Appointments Commission to make the necessary selection before the bodies themselves come into operation. It should not be necessary in any circumstances for the Minister to make his own preferential temporary appointment in advance.

Section 23 contains something which, although I understand the meaning of it, could easily be understood to mean something else. I refer to subsection (2), paragraph (b) which states:

an even number of other persons of whom half shall be selected by the Minister from a panel of persons nominated by such organisation (or organisations) as is (or are), in the opinion of the Minister, representative of the class of officers to which the officer concerned belongs, and half shall be selected by the Minister from a panel of persons nominated by the chief executive officer to the health board.

I would suggest the replacement of the fourth last word, the preposition "to" by the word "of" and it might be further clarified by the insertion in the second last line of the words "persons nominated for that purpose", that is the purpose of the removal.

This would be a matter for the next Stage.

I appreciate that and I propose to table an amendment, but the matter is so obvious that the Minister might wish to anticipate me by making the necessary amendment.

I should like to refer to section 30 as evidence of the kind of unwarranted new restriction which the Minister seeks to impose upon local authorities and health authorities and which we in Fine Gael believe is being applied, not for the purpose of improving the health services, but of preventing their further improvement. I believe that the Minister and the Fianna Fáil Government are concerned at the extent to which local authorities and health authorities have run ahead of them. They are concerned that public opinion, as expressed through the local politicians, is ahead of the State and has forced upon the Government, an unwilling Government who do not believe in social justice, a Bill for meeting the cost of a service which our people say must be met.

Section 30 proposes for the first time in our health legislation a limitation on expenditure by health boards which is phrased in the following words:

A health board shall not, save with the Minister's consent, incur expenditure for any service or purpose within any period in excess of such sum as may be specified by the Minister in respect of that period.

We, in Fine Gael, consider that that section is too restrictive and too absolute. It is a crippling restriction which is deliberately framed as such to prevent any further improvement in our health services, to prevent the kind of improvement and humanitarian advance which has taken place in recent years, notwithstanding the best efforts of Fianna Fáil to stop it. This is provided so that no development or improvement can take place, no relaxation of the penal health code can occur unless it receives in advance the benediction of the Minister. We are now replacing the experience of men in the field, the local dispensary doctors, the social welfare workers, the local politicians, with the say-so of officials in the Custom House who are far removed from the urgent needs of the people. We believe this is a retrograde step. Health services ought to be tuned to the immediate personal needs of the people. They ought to be responsive to human problems and human difficulties. God knows they seldom, if ever, percolate through the corridors of power to the isolated Minister for Health and his advisers in the Custom House.

Do Deputies realise what section 30 means? Under this Bill, instead of a health authority being able, as in the past, to say: "Whether the Minister wills it or not we must provide and will provide such a service" in future they cannot provide any service until the Minister gives his advance approval. If in the future a health authority estimate that the number of medical card cases which they may have will be 20,000 and receive the Minister's approval to that figure, no chief executive officer, no employee of the health board concerned can give to the 20,001st person applying a medical card without receiving from the Minister for Health the necessary advance approval. All the discretion, all the degree of responsibility which local officials and local health authorities have been able to apply in the past to human situations, to personal problems, is dissipated, is melted, is destroyed beyond redemption by this Bill and by section 30 in particular. In other words, as long as there is a Fianna Fáil Minister for Health in power any further improvement in our health services is blocked, is destroyed, is nipped in the bud. We in Fine Gael regard this as deplorable in the extreme and as contrary to the interests of our people.

Section 31 is the basically objectionable section at which we take umbrage in paragraph (b) of our amendment because it retains the injustice of financing half the cost of health services out of local rates. In case there was any doubt regarding the Minister's intention in section 31 he was kind enough to explain himself in his opening statement in which he said that the purpose of retaining it was to allow the Government at any time to return to the 50 per cent limitation which is imposed by section 31. This is in total conflict with the White Paper that was published by this Government when they were sweeping with a new broom in the autumn of 1965 and in the spring of 1966, in which the Government acknowledged that health services should not be paid for to any great degree out of the rates. Notwithstanding that acknowledgment, limited and begrudging as it was, that it would apply only to future extensions of the health services or what they called improvements, this section 31 contradicts the Government's own three years old admission that rates should not be used to finance any extensions to or improvements of the health services. Can we have confidence in a Government who contradict their own White Paper and take three years to do it, three years of doing nothing, three years which resulted in the failure and disappointment of this utterly inadequate Health Bill?

I should like to refer to section 35, paragraph 9, page 20 of the Bill which provides that:

The Minister may by order provide for the transfer of any specified health institution to a regional hospital board and may in such order provide for the application of any provision of this section to such transfer in the same way as it applies to a transfer to a health board.

The effect of this would appear to be to entitle the Minister to give away property belonging to a local authority, property which was built at the expense of the local authority, property which had been maintained in the past by a particular local authority and to give it away in such a manner as would deprive at least some of the people within the area of the local authority in question of the benefit of the services of such an institution in future.

It may well be that a re-orientation of our health services required the pooling of resources, particularly capital resources, and a better use of them. We suggest, however, that, if this power is sought by the Minister, he should also provide that he can increase the grants to be made from the Exchequer to such local authority as is deprived of an institution, to compensate it in respect of rights and opportunities and property lost in an institution so given away.

In regard to Part III I want to refer to section 39 which provides:

Whenever a health board is satisfied that useful service is being or will be rendered to persons requiring institutional services by the provision of such services in an institution in its functional area, the health board may, on the request of the governing body of the institution and with the consent of the Minister, provide for the institution any land which is shown by the governing body, to the satisfaction of the health board, to be required for the efficient performance of the functions of the institution or for the purpose of restoring or enlarging it.

I understand that the 1947 Act extends the meaning of the word "land" to cover any property. It does not just refer to "land" without any hereditaments. I want to urge upon the Minister that the provision in relation to institutional services needs expansion, and that we should not confine it to institutional services in the nature of what has up to now been understood by institutional services, that is, services in relation to in-patient care in hospital. We should also provide that the kind of gift or donation or acquisition which is provided for in section 39 can be given in respect of societies which provide home care, or day centres, or anything of that kind. It should not be related only to institutional care which suggests treatment for people in bed, or in-patient treatment. It should be possible to allow gifts to be given to the multitude of voluntary associations which are providing meals on wheels, clothing, home nursing, home social welfare care, and other treatments of that kind for people who can and should be maintained in their own homes and in the community. I would suggest that section 39 does not go far enough.

In section 40 the Minister proposes to establish by regulation a body to be known as Comhairle na nOspidéal. We in Fine Gael resent, in relation to this section and other sections, the fact that so much is not done in this Bill which could be done, and that, in default of doing it in this Bill, it is proposed to do it by way of regulation. Comhairle na nOspidéal will obviously be a very important authority in the future. We believe that whatever the Minister has in mind, whatever he vaguely describes in the section itself, should be spelled out in particular detail so that Members of Dáil and Seanad Éireann can properly assess it. There is no provision, as I understand it, to have the regulations made by the Minister establishing Comhairle na nOspidéal reviewed by this House or by the Seanad.

It is sought in this Bill to give power to the Minister to establish a body which will interfere radically with the running of the voluntary hospitals, which will jeopardise the authority and responsibility of the local authorities, which will interfere with the religious orders and dedicated and charitablydisposed people who own the voluntary hospitals in the running of the hospitals in the future. We are not prepared to give the Minister the kind of dictatorial powers which he seeks by way of regulation in section 40. We believe they are not warranted. They certainly are not justified by anything the Minister has said to date or in his opening statement. The scope of dictatorship which the Minister seeks in section 40 is not warranted by any of the needs for the better running of the voluntary hospitals.

I now move to Part IV which deals with the new norms for testing eligibility for the health services. Section 43 proposes to replace the Victorian formula which entitles people to free medical services if they are unable out of their own income or other lawful means to provide the services with a new and equally objectionable phrase which entitles them to the services if they are "unable without undue hardship" to arrange the services for themselves. This is giving new life to the means test. This is once again drawing across our society a new boundary, a new division between people with means and those without means. It is proposing to establish once again in relation to the health service an apartheid, a distinction which is not justified by our requirements.

Up to now objectionable and all as the Victorian formula was, it was left to each local authority to interpret it according to their own experience. We appreciate that this has meant a tremendous variation, a variation of from 18 per cent of the population entitled to free medical services in the Dublin region, to as much as 50 per cent of the population in the Carlow area and other areas and providing for an average entitlement of 30 per cent to free medical services. This might point to discrimination and inequality of treatment, but it may also point to a system which is responsive to local needs and requirements.

It is proposed now to replace this with a new formula which is unknown, new regulations which are yet unstated, new rules and new tests which are not to be adaptable to local requirements and needs, or compelling necessities of any individuals, prepared by the Minister according to rules which at this stage he is keeping to himself and will not disclose to the House. I appreciate that it is provided that regulations shall not be made until a resolution approving of the draft has been passed by each House but, as I mentioned earlier, that is not an adequate protection because our experience has been that the daily pressures on the services of politicians are such that regulations of this kind, which go to the root of the availability of health services, may well pass without getting the kind of examination they would receive if they were provided in a Bill such as this which is supposed to be so momentous.

We in Fine Gael appreciate that in accordance with the undertaking by the Government in their three year old White Paper, and in accordance with the undertaking repeated by the Minister to recent conferences of the medical associations, it is not proposed to increase the number of persons entitled to free medical and institutional services. We in Fine Gael consider this to be wrong, to be against the interests of our people. We consider that the Minister's suggestion does not answer the needs of our people and on that account we will vote against it.

We do not believe that it is true to say, as Fianna Fáil say in the White Paper and as the Minister repeats today, that hardship is not caused to 70 per cent of our people by medical expenses. It is caused. Day in and day out and week in and week out, there are families suffering hardship and want and considerable worry in paying for medical services and many families amongst that 70 per cent of our people are undergoing that kind of unnecessary suffering and hardship and loss and misery because Fianna Fáil assume that they are doing all right and refuse to come to their help. We in Fine Gael reject that because we know that, whatever Fianna Fáil statistics may suggest to them, the experience of life proves to the contrary, and I suggest that even the Minister for Lands should acknowledge that what I say is true.

I mentioned earlier section 44 and I shall not advert to it at any length except to reiterate that section 44 suggests that certain people are to be entitled to what is called limited eligibility. The level of entitlement fixed by the Bill in that section may be completely destroyed by the section itself which allows the Minister to wipe out of existence altogether by regulation a section or the Bill itself. We resent both sections 43 and 44 because they both ensure that medical services will not be available either on full eligibility or limited eligibility without proof and they require, as in the past, that medical services should not be available unless people go cap in hand to some local official or to a politician.

In section 45 it is proposed to introduce a new restriction. At present people who are regarded by a local authority as being in receipt of an income in excess of £1,200 a year may appeal to the Minister against such assessment, but the appeal lies to the Minister. Now it is provided under section 45 that the appeal may be to a person being either another officer of the health board or a person, not such an officer, appointed or designated by the Minister.

We do not consider it is worth while providing an appeal to another official of the same health board as has rejected the application in the first instance. Any health board will operate under a certain policy and if one official operating that policy turns down an application, it is practically inevitable that an official of the same health board will turn down the appeal. That is the end of the appealing provisions in this section. The sure way of killing people, the sure way of blocking a person from getting benefit is for the Minister to appoint the appeals officer from the health board which refuses the first application. We consider this to be wrong.

It is very interesting to realise that even where the appeal lies not to an authority independent of the Minister or the local health authority but to the Minister himself, as now operates, up to one-third of the present appellants succeed in their appeal. That is a very large proportion. The Department of Health are not noted for generosity, but nevertheless one-third of the persons who appeal against the findings of the local health authority succeed in their appeal, because the appeals are made to some person who is independent of the local authority concerned. We believe it is wrong that, as is now proposed, the appeal should be made not to the Minister or the Minister's Department but to another official within the authority which has turned down the application. This is a worthless appeal. We in Fine Gael think it is an effort to reduce the number of successful applications. We regard it as highly objectionable.

I should like the Minister to say if I am right in assuming that for the first time there is a right of appeal against the refusal to grant a GMS card, that at the moment there is no such right of appeal but that now it is proposed to give that right. We would regard that as desirable and as an advance, but we think it is a pity that, if that advance is, as I understand from the Minister's nod, being made, the Minister should make the retrograde step of seriously qualifying the existing right of appeal in relation to what is called the middle income group.

Section 48 is a provision which entitles the health authority to recover charges from people who receive benefits without entitlement to them. Can the Minister say if this entitles a health authority which has maintained a person in an institution or has provided medical care for a person to recover from the person's estate when the person dies the cost of providing such care? This matter, to say the least of it, is in some doubt. There is at least one law case pending on this issue of whether or not the health authority may recover from a deceased person's estate the cost of maintaining the deceased in a mental institution during his lifetime, the estate consisting of farm lands which could not be converted into liquid assets for the purpose of paying for care during the person's life.

I appreciate that it is proposed in this Bill to provide that a dependant's income will not be taken into account in ascertaining entitlement to service in the future. It may well be that a case can be made for recovering from a deceased person's estate the cost of that person's maintenance during life, but if it is proposed to do this, I would suggest it ought to be spelled out in this Bill.

My experience is that it is never worth it anyway.

Never worth pursuing a claim to an estate?

Yes, it is never worth pursuing that claim.

The case I have in mind is that of the maintenance of a person for 30 or 40 years in a mental hospital. The only property was an under-used piece of land whose capital value is quite substantial. I think the claim of the health authority would be for about £12,000. If the land were sold for £24,000, one can see the moral justification for the recovery of money from the estate, particularly when it might be some remote relatives who could not have cared less about the deceased who might benefit if the local authority did not recover the money. It is the kind of problem that ought to be provided for here because it is fair to argue, I think, that distant relatives, or others, should not benefit where the community has been bearing the cost of the maintenance of people in institutions. At the same time it is highly desirable that there should not be any resort to the capital of the infirm or the sick, mentally or physically, but it is permissible, in my opinion, and proper that the State should recover from the estate of such deceased persons.

Section 52 refers to the right of a person entitled to treatment under the Bill to opt for in-patient services of his or her own choice. We will all agree it is desirable that people should be given that choice. However, it is also provided that the Minister may make regulations to prescribe the payments people may make or which will be made to such people in respect of such treatment. I would urge that such payments by the State or the local authority in respect of services provided for people making their own choice should not be less than what the State or health board has to pay in respect of treatment in a public hospital. The practice to date has been that the State has paid less in respect of people making their own choice than it is prepared to pay in respect of those who go into public wards. The result has been that the State pays a great deal more because the State is driving into public wards far more people and the cost to the health authority and to the Exchequer is much greater than if people made their own choice and received a payment from the State commensurate with what the local authority is paying in the public wards. I would urge on the Minister that he should be generous when he comes to make regulations under this head.

Under section 57 (2) provision is made to enable the Minister to refund the actual expenses incurred by people obliged to purchase drugs and medicines and medical and surgical appliances. I paraphrase the section because my reading of it is that it entitles people to a refund of actual expenses. At the moment many people who are not entitled to general medical service card benefits are enabled to obtain drugs or medicines and medical and surgical appliances and they are entitled to receive the benefit without paying the bill. They are entitled to receive these things either direct from the health authority or on receipt from the health authority of an authority to them to go and collect the equipment or the drugs. My reading of section 52 is that, in future, whether they have the money or not, they must pay the bill before they get any refund or assistance from the health board or from the Department. We regard this as providing assistance too late because the effect will be that many people will postpone getting the kind of drugs and medicines or medical or surgical appliances which they can now get by making arrangements with the health authority in the first instance. We would urge upon the Minister that he should take a second look at this and ensure that the necessary assistance is given at the time of need and that it is not postponed until such time as the bills are paid because, if it is left as it is at the moment in this section, the people will in many cases put off getting the drugs, medicine or equipment until they fall over the cliff and land at the bottom; then they will have to be carted away into an institution and maintained there free of charge.

We, in Fine Gael, and the Dublin Health Authority welcome the provision which enables a health board to provide home nursing without charge. We have been giving this service for many years, with no assistance from the State, and entirely at the expense of the local ratepayers, but it has had this beneficial effect: for the first time in 30 years in Dublin, notwithstanding the increasing population of elderly people, we now have as of today no waiting list for institutional care for old people. That is because we have kept these old people at home in good health. We have prevented old people from going into institutions. Heretofore, until we provided home nursing for the old and infirm, the only care for such people was in St. Kevin's, in St. Mary's, or somewhere else. They could join the queue awaiting entry and, if they survived until they had reached the top, they were in, but often too late to be cured. Now we provide out-patient clinics in St. Kevin's and St. Mary's and old folk centres which constantly review the old people, advise them and provide medical services for them. The result has been that we have been able to reduce substantially the number of old people looking for care in costly institutions, in which the cost of the care is five to six times greater than the cost of keeping them at home and in the community.

On section 59, might I express some reservations? The section says that a health board may make arrangements to assist in the maintenance at home of sick and infirm persons or their dependants or of persons eligible for institutional assistance under section 54 of the Health Act, 1953, without charge or at such charge as the chief executive officer of the board considers appropriate. This again confirms what is being done by many health authorities, including the Dublin Health Authority, but it does not go far enough. A number of health authorities are at the moment providing assistance for widows and children. A widow is not necessarily a sick and infirm person or a person eligible for institutional assistance but, because the health authority provides some kind of home help for a widow with young children, the widow is able to go out to work and thereby provide an adequate income for the home. I suspect this is an omission through accident and not through design and I would urge that another look be taken at the section to ensure that cases of that kind can be provided with home help.

I do not want to be carping in my criticism. The Minister knows my generous heart. It expands as big as Deputy Burke's at times. Section 62 repeats, 3½ years after the famous White Paper, the promise to increase maternity grants from £4 to £8. I do not know, and the Minister does not know as of certainty, on what the maternity grant is spent, but I think it is fair to regard it as "beer money". The increase from £4 to £8 does not even compensate for the increase in the price of beer since 1953, when the grant was last fixed at £4. If you are going to have a maternity grant to assist a mother who has given birth to another citizen you ought to make it something decent, like £20 or £25, and not just a miserable £8. I understand the price of the pint when the maternity grant was £4 was 1/2d and that was after Deputy MacEntee's famous hairshirt Budget of 1952. The price of a pint of beer today is anything between 2/7d and 3/-. The beer money to celebrate the birth of a new citizen is not even sufficient to compensate for the increase in the price of beer. It is unworthy: it is miserable. If it is proposed to increase it at all, make it something decent to allow the mother to buy some clothing or pay enough to buy a pram or some other necessary equipment for the child. A sum of £8 would not go very far in these days. It is not worth spelling out in a 15line section in such a Bill.

Section 63 proposes to provide milk for mothers and children where the parents are unable, from their own resources, to provide the children with an adequate supply of milk. This certainly goes back to the Queen Victoria formula. Again, either we should be generous about providing this or we should leave it out altogether. I do not think it does anything which is worthwhile spelling out in this section. It is certainly not doing anything which is not already being done by any health authority worthy of the name.

Chapter V deals with other services. It provides that a health board shall make dental, ophthalmic and aural treatment and dental, optical and aural appliances available for persons with full eligibility and persons with limited eligibility. This is repeating a section that is already in the 1953 Act and that is not being implemented. There is no penalty clause here applicable to the Minister or to any health board which does not implement it. Is there any sanity in asking this Legislature to enact a section of this kind when the State fails to take the steps necessary to ensure that a health board is in a position to apply it? It is like saying that a health board shall keep everybody alive—full stop—and nothing more. We need to do a great deal more to ensure that they are in a position to provide these services. Otherwise, we should not go through the mockery of suggesting in a Bill that we are going to provide something that, in fact, we are not going to provide. This leads to justification for the conclusion that this is no more than a bit of window dressing which must be put in the window because it was promised years ago—even before the last general election—but, because of its absence, it had serious consequences for the Government at the last election and it must now be inserted here before the Government are found wanting twice over.

Section 66 deals with rehabilitation services. I should like to make this comment. Subsection (2) provides that, for the purposes of subsection (1) of Section 66, a health board "may provide and maintain" premises, workshops, farms, gardens, materials, equipment and similar facilities for rehabilitation. Under present law it is provided that health authorities or local authorities may make "arrangements for the provision of" these premises, workshops, equipment, and so on. Why the change in terminology? It suggests that health authorities are to be stopped doing in future what they may now do, namely to provide grants, subsidies, equipment and premises to voluntary bodies which are giving premises, workshops, farms, gardens, materials, equipment and similar facilities for the education and re-training successfully to work of physically and mentally disabled people. I would urge upon the Minister to take a look at this. We, in Fine Gael, believe that much of this work is better done by the voluntary agencies than by the local authorities or by any institution of State. The section as it is drafted suggests that the obligation is an exclusive one and would not entitle the health authorities or health boards to give assistance to other people in these things. I suggest we ought to be aiming at an expansion of help to voluntary bodies, and I think it is in the mind of the Minister, judging by utterances I have heard him make on many public and, indeed, on private occasions.

I shall not refer to Chapter VI except to say once again that we are horrified at the extent to which this House is not legislating for health reform but is being asked to give to the Minister and to faceless officers untold powers to interfere with existing and future health codes. We think it is entirely wrong. Public health is a matter of sufficient understanding by everybody in our community to be put before this House and for the lines to be laid on which the engine of the health services can run. We think it is wrong that from this Dáil and from Seanad Éireann we should delegate this terribly important responsibility to people who will not be answerable to this House or to the community in general.

On section 75, my comment is primarily one for Committee Stage. Of all things, it deals with the Rats and Mice (Destruction) Act, 1919. Having regard to the many omissions in this Bill one might wonder why we are dealing with that Act, but I gather that it is because of a request by at least one health authority so to do. Section 75 provides that, notwithstanding section 11 of the Rats and Mice (Destruction) Act, 1919, whenever a health board is unable to trace the occupier of land, a notice under section 5 of that Act may be served by affixing the notice on or to a gate, door or a prominent part of the land. The degree of inability is not quite satisfactory. I think it ought to read "...it is unable after reasonable efforts..." or something of that nature. Otherwise, the section as drafted will still leave health authorities in a state of uncertainty as to whether it is now open to them, having made certain efforts, to affix notice to the land. Primarily, this is a matter of drafting. Being a lawyer, the Minister will understand the difficulties which arise in relation to the service and the giving of notice, and so on.

That matter would be more relevantly a Committee Stage point.

I agree. I am moving away from it now. I would appreciate an explanation by the Minister of section 76, the understanding of which, I am afraid, has somewhat escaped me. It may purely be an accounting formula: I suspect it is. However, it is not quite clear in itself—even with the reading of section 31—what is intended.

On behalf of Fine Gael, I should like to express disappointment that the Minister proposes to transfer public assistance from health boards and health authorities back again to local authorities. If public assistance has any meaning it is because it provides social service because it provides subsidies to individuals to keep them and their families as healthy, viable human beings. Public assistance is essentially a social service. Mark you, it is proper to say it should not fall on a local authority and it should not fall on a local health authority or local health body. It ought to be conducted by the State Welfare Department but as long as the State is unwilling to accept responsibility for this, which we in Fine Gael believe it ought accept, then if it is to be left at local level it should be left to the health authority which has some experience in and understanding of human problems.

It is fair to say that there are not many public assistance cases which are not health cases as well and the kind of case problem which arises for relief in the field of public assistance is the kind of case problem which comes under the notice of the public health nurse, the social welfare worker, the local dispensary doctor and the multitude of people concerned with human beings and their health problems. It is beyond us why the Minister is now proposing that public assistance, which has been successfully conducted by health authorities for many years past, should be transferred back to local authorities, to the sanitary sections of the local authorities, to the section of local authorities concerned with sewers and rat infestation and leaking roofs and so forth. Public assistance is a human problem; it is not a structural problem or a sanitary, physical problem and ought to be preserved within the responsibility of health authorities or health boards, it does not matter what you call them. Certainly it should be left to the care of those dealing with human beings and not those dealing with the physical problems which are the prime concern of the sanitary section of local authorities.

We believe that the proposal in this Bill to transfer public assistance away from the health authorities back to the physical, sanitary services is an effort on the part of the Minister for Health to put a brake on the development of the health services. This is the clear message in all sections of this Bill, that the local people, the local authority and the people themselves are running ahead of the Minister and the Department and making demands which the Minister and the Fianna Fáil Party are not prepared to accept and want to apply the brake of central authority to stop all this. We have had that in many sections of the Bill and here we have it in relation to the service of the last resort, the public assistance, and we in Fine Gael find that that is wholly unacceptable. That is why, although we appreciate the possibility that our political opponents will take unfair advantage of it because we so do, we in Fine Gael have decided to oppose this Bill because it preserves most of what is wrong. It does little or no good and if it does any good it more than destroys that good by the amount of harm it does. It proposes little or no improvement in our health services but it is making certain that beyond yea or nay as long as the Fianna Fáil Government remain in power and as long as they have the control they now seek under this Bill there will not be one more whit of improvement in our health services, the improvements which everybody with a conscience desires, improvements which everybody in pain or suffering has a right to demand of our community.

It is for these reasons that we oppose this Bill. It fails to provide what the White Paper said it would at least examine. It fails to provide what the Minister himself accepted as worthy of consideration, a comprehensive health service available to everybody based upon insurance principles. It retains what the White Paper, the Minister and many Fianna Fáil Deputies and councillors, including Deputy Joe Dowling, have accepted as being wrong, the injustice of financing half of the cost of the health services out of the local rates. I have heard no person denounce that in more vehement phrases than Deputy Joe Dowling in the Dublin Corporation and in the Dublin Health Authority and I will be looking forward to hearing his equally vehement condemnation in the course of the debate on this Bill. I have no doubt that what you need in public life is responsible people, people of spirit and responsibility and I am sure he will refuse to lend any support to a Bill which continues what he and his colleagues in Dublin Corporation accept, and keep shouting that they accept, as being wrong.

We reject the Bill because it gives excessive power to the central Government without any additional burden being accepted by central Government for the cost of the services. The only justification of the White Paper for interfering with the rights of the local trations is spelled out in the last chapter in the White Paper, in which they state to the Health Bill, in which they state there is no justification for any interference unless the State is going to bear additional costs; if the State is going to bear additional cost then the interference must take place. This Bill says: "50 per cent, thus far and no further" and having said that it says: "We are going to wipe your eye and take away powers you had." We regard that as wholly unacceptable. May I finish on a personal note by sympathising with the Minister on having had to justify such a miserable piece of legislation?

A petty piece of typical Fine Gael humbug.

I formally second the amendment and reserve my right to speak later.

(Interruptions.)

It is a miserable Bill.

If that is the best the Deputy can do on behalf of his Party——

The Minister should resign.

——I know how much interest he has in the health of the people.

Deputy Ryan has made the finest speech ever made in this House. That is what is maddening the Minister.

I fully admit to a failure on my part, after a long and careful study of this Bill, fully to understand it. I do not feel ashamed of that because the same admission has been made by newspaper correspondents and political observers, by Irish Medical Association doctors, by radio and television personalities and local government officials. I admit to being somewhat bewildered by the phrasing of the Bill, by the regulations in it and the various other matters which are all part of it, to a most unusual extent. What the people will think of it, the people the Bill is supposed to serve, and I presume interest, is anybody's guess. Seasoned newspaper personnel who can usually grasp things and clarify difficult phraseology admit that they see little in the Bill except difficult cross-references and so on. It is impossible to assess the value of the Bill until we realise what regulations the Minister will make. Therefore, I propose to treat the Bill on the basis of reserving judgment until we may get, through discussion on the various Stages, more detailed information from the Minister.

Deputy Ryan, for one who put down a motion refusing the Bill a Second Reading, made an amazingly long attempt to discuss it in full. I have not the ability, perhaps, nor the eloquence and certainly not the hard neck to go through the tortuous performance we have had here since about 7 o'clock. If the Bill is so innocuous or useless, the Deputy took a very long time to say so. I could say it much more quickly. I propose to give the Bill fair consideration. I told the Minister for Health on the Estimate that I would examine the Bill on behalf of the Labour Party and consider it and see what, if any, good points it contained. Such points would have the support of my Party. We believe in gradual progress. Points in the present Bill that would improve present standards would certainly get our support. If there are objectionable features, we shall oppose them.

While I did not expect the Bill would come up to what the Labour Party would desire for the people we hoped that at least certain things would emerge. As far as I can judge, there are advances, but where these are of a definite character they are very limited. In his opening speech on the question of eligibility for a medical card the Minister quoted the old Poor Law phraseology that was enacted in the 1953 Act in regard to notification of entitlement to a medical card—unless you are unable to provide for yourself, and so on. The change in this 1969 Act is not wonderful. It means the very same thing—unless you cannot provide for yourself you will not get a card. That is only a point of interest that is of very little importance; what matters to those on the receiving end is whether they get the card or not.

What we like are the improvements. I freely acknowledge that the new eligibility test will be based only on the earnings of a man and his wife and not on the combined income of the family. That is an improvement which merits the support of my Party. Under the 1953 Act originally eligibility depended on the income of the bread-winner of the family and dependants, I think, who were over 16 years of age were entitled to a medical card in their own right provided their income did not exceed a certain amount. But, under the new regulations made under the 1953 Act, these benefits were lost because the total income of all people earning and living in the house was combined. A vast number of families were thus deprived of the useful benefits of a medical card.

It is difficult to assess the value of the power the Minister is taking to define by regulation the classes of people who will be eligible. If it means that he will define, say, old age pensioners, and widows and orphans as eligible and, as I would hope, all who are insurable under the Social Welfare Acts, that would be a further improvement. I do not know what the Minister will do but at least he is taking power to do something. Prior to this, eligibility was based on a variety of considerations. What the county manager or an executive officer in County Tipperary thought was right was not what somebody in Wexford or Waterford thought was right. There was no uniformity. With the new system let us hope we will have uniformity and that people will know their rights and that there will, perhaps, be less need for them to appeal to local representatives or politicians to fight cases for them. It is an improvement but how good it will be is difficult to say. Certainly, if the Minister uses this power as I hope he will, it will do a certain amount of good.

The same applies to the power the Minister is taking to vary the degree of eligibility by regulation in cases of limited eligibility. I think the Minister is wise in giving himself this power and I see this as an improvement.

I heard Deputy Ryan refer to the right of appeal to the Minister. I was very keen on this and I pressed the Minister's predecessor, the late Deputy O'Malley, to have this right of appeal provided. Having given the right of appeal, I would be disappointed if the Minister adopted the tactics Deputy Ryan suggested he might adopt, of appointing an official of the same authority that had refused the application to try the case again. If that were done the right of appeal would not be of any value, but I do not believe any Minister who would bother to introduce the section would contemplate such a procedure. My only fear is that, because of the almost complete authority that will apparently rest in the Minister's hands on most questions, a right of appeal to the Minister will be much the same thing. Let us hope it will be something like the right of appeal in the case of old age pensions and that appeals officers will be appointed who will decide things, something on the lines of old age pensions appeals. To take a case from one individual and let somebody else have a look at it is, I think, an advantage and I welcome that change.

I have found a number of improvements in the Bill. There are omissions and things with which I disagree but I want to be fair and point out what I hope will be good. Where an in-patient in a hospital has a certain choice, where he can opt, for instance, to go to a nursing home instead of a hospital or somewhere other than the local authority hospital, I think he is in a better position than he was formerly.

One particular individual who suffered an accident at work opted to go to a doctor whom he knew would put him back at work almost immediately. Since he did not go to the local authority he could not get any refund of medical fees because under the Act governing occupational injuries he should avail of his local authority doctor. However, in his opinion the local authority doctor was not capable and so the man went to somebody else. Under the new regulation, I believe, he would have that right and I think it is only proper that he should have that right.

The abolition of special charges for out-patients is a good thing. This had more of a nuisance value than anything else. While 7/6d may not seem a lot, it could prove quite expensive for a person who had to have a number of X-rays at 7/6d each.

The detection of children's defects for those other than in the national schools also is a very good thing. The fact that children even in pre-school days can be treated and can get corrective medicine and surgery is a very welcome change. On the question of children in the higher income group, I heard Deputy Richie Ryan speaking about the one-fifth and proving that one-tenth at the moment will gradually become one-fifth. I do not think one will find a great number of children of the higher income group in national schools. There is not a lot of validity in the arguments he made.

The main advantage that I see in this Bill is the choice of doctor. This has been a long and badly-felt want. I have known of numerous cases where a good doctor-patient relationship could not be possible because of the fact that a person was compelled to attend a local dispensary doctor in his area and that person, in private life, might have had a difference of opinion with the doctor only a week before-hand or, worse still, his wife might have had a difference of opinion with the doctor. In circumstances like that, it was desperate to find that a person had to submit himself for treatment to that doctor, notwithstanding the fact that the doctor would be more than likely to treat him to the best of his ability.

I am glad, too, that it will be possible to get drugs from the local chemist, in whom the person will have confidence. These are advances, perhaps limited, but, in my opinion, they are very worthwhile advances.

The question of limited eligibility for drugs in the cases of long duration illnesses is also covered in the new Bill, but I think that this was fairly well exercised even under the old Act. It certainly was in my local health authority. But perhaps this was due to the pressure we exercised on them and due, too, to the very fine type of county managers we have had, both the late county manager and the present one. Nobody suffered any great hardship as long as they went through the proper channels and sought the help of the officials there.

The increase in maternity grants is also very welcome. The increase from £4 to £8 will be an advantage to the type of person who needs the money. I know there are isolated cases in certain places where the money is used to buy drink but I do not think that that should be used as a reason for ridiculing the grant.

I find a lot of good points in the Bill but, as I promised when I spoke on the Health Estimate, I shall treat the Bill as I see fit and the points I am making now are my personal views. I give them for what they are worth and, where I come across things I do not like, I will be just as frank about them.

The easing of the means test for dental, aural and ophthalmic surgery is very welcome. Eligibility will now depend on the income of the man and his spouse. This is something which I very much appreciate. The real value in the improvements to the Bill are, in my opinion, the choice of doctor and the fact that persons can go to their own chemist for drugs. There may be many other improvements in the Bill but we shall know this when we know what regulations the Minister intends bringing in. There are odd dangerous sections in the Bill.

The question of 10/- a day for the middle-income group is removed and the Minister may fix an amount. Now you know 10/- a day is the maximum. At least you are guaranteed it will not be more than that. It could be anything from 1/- up. Under the new regulations, what happens if the Minister says it can be 15/-, £1 or 25/-? That certainly would not be an improvement. I would like it spelled out that there will be a maximum charge for days in hospital over which it cannot go. I am not too happy that the Minister will just have the power to make the regulations for this. This is one of the bad effects of the Bill which I see. I will be endeavouring to persuade the Minister, or I will be endeavouring at least to make a case, that he should not or cannot go beyond a certain limit.

Section 68 is a section where authority is being given to health boards to carry out tests for certain diseases. It strikes me from the drafting of the section, which I do not want to read out now, that in those cases there will be compulsion. I would like to see a provision that no person will be compelled to accept those tests, that they will be taken only of a person's free will. This may be a very small point. While I appreciate that most people would be very willing to accept the tests and that the health board will have the power to carry them out I do not think there should be compulsion because if compulsion comes into it there will be much less ready response.

There is no question of compulsion.

One of the things I hoped to see in the Bill was that all insured workers would be covered. I believe and understand from what the Minister has said in his opening speech that the cost of health services lies very heavily, right up to the top, on the middle-income section. I believe that much of the man days lost is caused by this. An enormous figure of man days lost was given to me by the Minister for Social Welfare in reply to a Parliamentary Question. I have mislaid it but I know the number completely outweighed the number of days lost by strikes, whether official on unofficial. If medical services were made available right up to the insurance limit of £1,200 it would repay itself and much of the time lost by sickness would be recovered, less hospitalisation would take place and there would be less medical attention needed. The mere fact that people have to pay £1 to a doctor for a visit, which means a lot to a man earning £13 a week, plus the cost of prescriptions, forces people to keep going until they reach the stage where they are compelled to drop out and give up employment. When this happens there is a long stay in hospital and very often people develop chronic illness which lasts for the rest of their lives.

I thought that under the new Bill the question of hospital charges, even the 10/-, would be abolished. I know the maximum of 10/- is very rarely charged. It is certainly not charged in many local health authorities. The charge varies from a couple of shillings a day and in the case of a long duration of illness a nominal sum per day is accepted. Nobody feels that 10/-a day is an extraordinarily heavy charge but if it is imposed over a long period it involves great hardship. Say a person falls and breaks a hip and is in hospital for nine months. The 10/- a day for that period represents a considerable sum of money to that person. I hoped all hospital charges would be abolished. There is also the threat of having to go to court because of non-payment. The Minister admitted that to sue a person with limited means in order to recover money is not a profitable exercise. That is the reason why I hoped this type of hospital charge would be dropped. I do not know what the cost would be but I should imagine it would not be extraordinarily high. It would probably be only £250,000 or so over all the various voluntary and local authority hospitals and so on. I should imagine that the administrative expenses offset would be about £150,000. I also hoped there would be absolute choice of doctor, specialist and hospital, but I see there is not. That would certainly have been a great improvement.

On the question of new boards, I disagree somewhat. I know we must have new boards if there is a regional control but I still feel the local authority representatives, the people elected by the people, should have at least a majority on these boards. I know they are catered for as to one-half the membership of those boards but the Minister can nominate the other half and also reserves the right to nominate the chairman and vice-chairman. If they are opposed to one another, one anti-Minister and the other for the Minister there is an equal balance. The appointees of the Minister are the deciding factor here. This is a great loss to local authorities in regard to their rights to be adequately represented on those boards. I recognise the fact that doctors, nurses and pharmacists have a right to be appointed but local authorities, the representatives of the people and the ratepayers should have the largest representation and the final say. The nominees of the Minister on such boards would not have to be elected. The elected representatives should have a majority. If you had two from, say, Waterford, two from South Kilkenny and two from Carlow that would be all right. I would like the majority of the board to consist of public representatives. I would want the election of a chairman and vice-chairman to be the right of the elected representatives rather than of the nominees of the Minister. The members of local authorities are the representatives of the people who pay the piper and they should be entitled to call the tune. There is a good deal to be said against the system of appointments suggested in the Bill.

I read with interest that the Minister said to the IMA that he was prepared to sit down with them and discuss this with them and if there were difficulties he would iron them out. I wonder would he extend the same courtesy to Deputies who would be anxious, not maybe to sit down with him, but to stand up before him and put their points of view at a later Stage, say, Committee Stage? Would he agree to give them the same co-operation as he has promised the IMA? I agree he must co-operate with the Irish Medical Association and it is only right he should hear their views and accept them as far as he can but I warn the Minister that this Bill is for the people not for the IMA——

——or the doctors, and I would like to see the interests of the patients put first. Certainly improvements should be made for the other people but the Bill is for the patients. I would ask the Minister to remember that.

I want to make one other point. It relates to the Children Act, 1908, and the Adoption Acts. The Minister is aware of the unpleasant tragedy which took place in Waterford when an adopted child lost its life in circumstances of which I am sure the Minister is well aware. I have not mentioned the matter here before because for a period it was sub judice. Somebody was being tried before our courts. The fact is that the same thing could happen again. Our local authority nurses have not got the right in certain cases to carry out the provisions of the Children Act in relation to children adopted under the two new Acts. I feel it is the duty of the Minister to implement amending legislation to the Adoption Acts. If the Minister has examined the Waterford case he knows that that baby should not have been handed over to the care of that woman. It was done illegally because she was not competent within the terms of the Acts to accept the child. It is the duty of the Minister and I appeal to him to plug the loop-holes and to see to it that adoption regulations will be enforced vigorously and enforced by the nurses of the local authority. They are the most competent people to carry out the work of supervision. As well as being social workers they are midwives and people with a high medical skill. A child, whether adopted or not, needs regular attention. A child is usually adopted by a woman who admits, by the very fact of taking the child, that she has no previous experience of the handling of infants but wishes to do a good act and needs the assistance of qualified, experienced people. However, as I understand it, under the Adoption Acts nurses have not even the authority to visit these adopted children if they have been put through private adoption societies. I would ask the Minister to examine personally that position and if necessary to bring in, either by regulation or, if necessary, by amendment of the various Acts, some safeguards so that the Waterford tragedy will not be repeated and so that we will learn from that case and thus safeguard other lives.

I should like to promise the Minister my support and the support of my Party for the parts of the Bill that we feel are some improvement. The Bill is not anything like what we had hoped for, but we know that you just do not go forward immediately. Even in the event of the Labour Party coming into power at the next election they could not immediately introduce a complete social health service. Any step forward will meet with our approval. The only regret we have, I think, is that the Bill has been so obscured by the various regulations, amendments and sections that it is very hard to get to whatever value it contains. Let us hope that on the Committee Stage we will be able to examine the Bill more closely and perhaps do something to improve it.

Before commenting on the Bill I should like to pay tribute to Deputy Kyne for his very fair and constructive contribution. It was in sharp contrast to that of Deputy Richie Ryan who made one comment which was worthy of Boyle-Roche. He said the Bill did no good but if it did any good that good was undone by the Minister. I do not know what to make of that but it certainly was not a constructive contribution to the Bill.

A Health Bill is one of the most important Bills that can come before the Oireachtas. Before going into detail on the Bill we should examine our attitude to a Health Bill and find out what a Health Bill seeks to attain or what it should seek to attain. It should not only preserve that which is good in preceding legislation but it should try to improve and should try to eradicate any defects in previous Acts. In this latter half of the twentieth century it is very necessary that any health legislation we enact should, apart from ensuring that the ailing body shall be tended, also ensure that the dignity of the individual is preserved to the highest degree. We have seen in neighbouring countries Health Acts being brought in, containing some provisions which surely cry for vengeance, provisions which reduce people to the lowest form of living or perhaps of dying. I am referring to Acts in other countries which allow practices which are the very negation of the dignity of a human being. While we in this country have not yet had to face the problems that other countries have had to face, even though we are a small country we could perhaps, by our outlook and in our legislation for the care of the ailing and the old, set an example that might remind those in permissive societies of decent living and the need to ensure dignity of the person.

We on this side of the House believe, and I am sure this belief is shared by the people in the Opposition Parties, that as far as our resources will allow any ailing person, whether he is suffering from an organic disease or has merely grown old, should be given the best treatment that our medical schools and our physicians can provide. Indeed, by profiting from what is good in other countries, we should be able to boast that no person because of lack of means will be without the necessary medical care to restore him to good health.

This Bill seeks to bring that about as far as we possibly can. We have had many Health Acts since the State was founded and no doubt each of these brought some improvement. It is very easy to be emotional when discussing Health Acts. During the last 20 years we had displays of emotion over Health Acts which contributed little to improving these Acts, though they may have sounded well and perhaps impressed a section of our people who do not think too deeply. This day is passing and the people realise now that the Government are doing their very best to give us a really good health service.

This is a Bill which one cannot absorb in one hour's reading. I am sure the Minister will be helped by Members of the House after a thorough examination of the Bill and, if necessary, it can be amended. On reading it, one realises the vast amount of work the Minister and his officials have put into it. It is a step forward. Of course there are defects in it but these defects are there, not because the Minister does not want to remove them, but because of the fact that our resources are not unlimited.

We must be factual. We must get the best possible medical services for which the people are prepared to suffer taxation. It is being realised more and more that a completely free health service is a mirage. We have heard in other countries the slogan: a health service free for all; but we must realise that there is no such thing as a free health service. It must be paid for in some way. Therefore it is our duty to ensure that the people who can pay will pay and that those who cannot pay will have the best possible service.

When a wage earner is in hospital he has the additional worry of wondering how he will meet his hospital bill. This worry must be removed so that when he is better he can lead a full life without having to face a colossal hospital bill. We know that we cannot have a perfect society and that no matter how hard the Minister tries to bring in a perfect Bill he cannot do it, but we must do our utmost to help the Minister and his advisers to perfect this Bill.

There are several sections which one could dwell on for quite a long time. In the time at my disposal I do not propose to do so, but I wish to refer to certain categories of our people who are suffering. I want to refer particularly to the aged in our institutions. It is not good enough to pack an old person into an institution and say: "There you are. Society has done its duty. You are packed into an institution. You will not starve. You will have shelter." I suggest that we must go further. We must ensure that, even though it is sometimes necessary to put old people into institutions, this does not become the pattern. We must strive to keep our old people at home. The Minister has helped to do this by the provision of the home nursing service. We must seek to maintain the dignity of the old. This will cost money, too. It is very easy to put an old person in a home and leave him there but that is not enough if we intend to build the society which we all want to see.

We must go further and ensure that the old person or the mentally retarded person is not just cast into an institution and forgotten. We must provide the best possible service because our treatment of the old and the mentally handicapped is one of the things which preserves a proper balance in our society. In other countries old people are subject to many dangers in institutions, so much so that they fight to the last before going into an institution because they are afraid of the fate that awaits them there—and not from natural causes.

On this aspect we must have regard to the nurses in these institutions who dedicate their lives to looking after these people. We must ensure that these nurses and doctors are paid the highest salaries possible. Unless we have a contented medical staff in an institution it will not be a good institution. These nurses and members of religious orders must be made aware of the fact that we are behind them and that we recognise the work they are doing. We must play our part in ensuring that they are rewarded financially. Of course there are many religious orders who do not think of a reward in that way but, at the same time, we must ensure that they are not taken for granted and that society appreciates their efforts.

Parents of mentally retarded children have the frightful worry of wondering what will happen to the children when the parents die. The Minister spoke yesterday at a function outside this House and he gave very satisfying statistics showing that the number of places for these children is increasing all the time. Until medical science can overcome such problems as mental handicap, if ever, we must show that there is a place for them in our society. If necessary they must be put in institutions and, if not, our outside services must cater for them. While institutional treatment is sometimes necessary, and sometimes the only answer to particular problems, it is also very costly indeed. If you examine the figures you will find that hospitalisation eats up a tremendous amount of money. Therefore we should try to keep people out of institutions.

I made a suggestion before in relation to local clinics having a mobile squad of doctors and nurses who could perform minor operations in the homes. If the maternity hospitals in this city and other cities can provide such a service I do not see why we cannot have it extended to cover simple ailments.

Debate adjourned.
The Dáil adjourned at 10.30 p.m. until 10.30 a.m. on Thursday, 17th April, 1969.