Any improvement or any proposed improvement in the health services, even as an interim measure, is to be welcomed. Therefore, we are prepared to support many of the proposals in the Health Bill before us. However, when it comes to deciding on what should be in the Health Bill and on what should not be in it, one occasionally finds that matters which appear adequately to be covered in White Papers disappear in smoke when it comes to putting them in black and white.
Before I go any further, I want to comment on something said by Deputy Moore whom I always recognised as a reasonable man in this House and who usually makes reasonable contributions. I am sorry he has left the House before hearing what I now have to say about him. He seems to be attempting to adopt the mantle of his colleague in the Ballsbridge area and to be aiming for the tony vote there by attacking expenditure which is for the benefit of the middle and the lower income groups. Indeed, I suppose he will come along next week and ask the Minister for External Affairs to state that the regime in Greece is the right one. He would seem to be following along that line. I am glad to say that nobody in Fianna Fáil, any more than in Fine Gael or Labour, ever before referred to the action taken by the inter-Party Government, when Doctor Noel Browne was Minister for Health, in the erection, staffing and carrying on of TB hospitals which almost completely eradicated TB, a dreaded scourge, as emotional outbreaks of hospital building, or the erection of a rash of hospitals. Would anybody except somebody like Deputy Moore, who obviously does not understand what he is talking about, make such a statement? I hope it is the last time that this House should have the doubtful pleasure of listening to comments like that.
The Minister for Health, on a previous occasion, admitted that the attempt made to eradicate TB at that time was a job well started and well done. I heard him saying that myself. Now, 20 years later to find somebody trying to decry it is beyond comprehension and I can only imagine it was for petty political purposes. I regret that it was Deputy Moore who made the comments because he is normally a decent Deputy, and that such an attack should have been made on something generally recognised as having been one of the greatest things ever done in medicine in this country. It did not wipe out TB completely but it was very successful and the fact, as Deputy Moore said, that the hospitals are not needed now proves that it was very successful. I would suggest that the hospitals are needed and furthermore that a number of them have been put to very good use. I suggest further that the Minister will find that if the staff can be made available a lot of things can be done with those hospitals if we do not need them for the treatment of TB.
Thank God it appears that we are needing less and less of them for that purpose. I am very sorry to have to say this and possibly Deputy Moore did not consider it before he made the statement, but it appeared to have been made simply for the purpose of pleasing somebody else who is not here at present. It was a comment that I would not be surprised to hear coming from one of his colleagues and it is possible he is aiming at the mantle and the tony vote of Deputy Seán MacEntee.
That is a long way from what is contained in the Bill. When the White Paper was issued the Minister visited the various local authorities and discussed matters with them, and as one of my colleagues who is now dead used to say, he is very fair, free and frank and he proceeded to answer the questions put to him and made what we consider to be honest comments in regard to those questions. In regard to the choice of doctor—providing the same facilities for eligible patients as are given to private patients of the doctor—this is from my notes of the Minister's visit to Navan—all of us, on every side of the House, for years have been stressing the necessity for having a choice of doctor for patients. One has only to live in the country— I know nothing about city conditions, I am sure they are entirely different— to realise the hardship that can be imposed on a family not, as Deputy Kyne said yesterday, because the doctor and the patient have had an argument, or some members of the doctor's family had an argument with a member of the patient's family recently but because, as I have known to happen, disputes which sometimes had something to do with medical attention and in other cases had nothing to do with medical attention had occurred back in the time of the grandfather of one and the father of the other. As a result, the family had no confidence in the doctor and the doctor would prefer to go anywhere else than to the house of the family with which, to put it mildly, he was not on good terms. Nobody would suggest that the doctor would give less than the best treatment to the patient but the fact that those receiving treatment thought that that was so made the treatment which was being given almost useless in many cases. In many cases they would not go to that doctor and even though they could not afford it I have known cases where they would go eight or ten miles out of the district, even in an emergency, to get another doctor.
When the last Health Act was passed the matter became very complicated because while previous to that many doctors dealt with people according to whether or not they could afford to pay, when the Health Act and the medical card system was introduced they either had a medical card or they had not and when they went to a doctor who was not the doctor they should attend it meant that in almost every case they were required to pay. In addition to that, I have heard of cases where doctors attending people with medical cards commented that there was a car outside and asked if that belonged to the patient, or perhaps there was a television in the house or the house was well furnished and the doctors asked how did they get a card. I suggest that this had nothing to do with the doctor. Only on rare occasions did this occur but in these cases not only were people ill but they were belittled like this by a person who had not the common savvy to know that questions like that are not going to hasten the recovery of the patient.
Not so long ago I was told in conversation by somebody that he went to a doctor's residence on a Sunday afternoon as he had fallen from his bicycle and broken his arm. When he knocked on the doctor's door the doctor's head appeared through a window and the doctor said to the patient "Could you come back on Tuesday? I am rather busy now". The patient replied that he had broken his arm but that made no difference and he had to hire a car to go to hospital to have it attended to. I am mentioning these as very isolated cases but in this case the fact that the man had broken his arm meant that he was entitled to go to hospital anyway and the local authority would not crib. In normal circumstances there should be a choice of doctor.
I am sure if I mention Nobber the Minister will know what I am talking about. We have cases such as those which occurred in Nobber where there was extraordinary difficulty getting a dispensary doctor. This question of a choice of doctor may not work out and there will have to be a second string to this in order to ensure that there will be medical attention because it is conceivable that there would be areas in which there would be no resident doctor at all. I am sure the Minister appreciates this much better than I do. It is conceivable that there would be fairly large areas to which, unless there was an inducement, the doctors would not come. The Minister mentioned that such an inducement might be offered but I would like to see it spelt out in a better way than it is to show that there is not going to be, as a result of the passing of this Bill, a situation in which there will be large areas in which (a) the population are thinly scattered or (b) the doctors feel that the payments made in the area are not so good and that it would not pay them—they are entitled to consider that—and these people would be left without a doctor at all. This is a very serious matter. Couple that with further proposals in the Bill where the regionalisation of health services is considered and it tends to suggest that a very serious situation can arise. I propose to go further into that at a later stage.
The supply of medicines through retail chemists, or doctors, where there is no chemist, is a good idea. This was suggested in the White Paper and the Minister agreed with this when he spoke to us in Navan. It is a good idea but again we come to the problem which should be dealt with in some way. Chemists, like everyone else running a business, cannot be at their job for 24 hours a day for seven days and they have to have their hours of trading. More than anybody else in business that I know of they go out of their way to open their shops on Sundays, on bank holidays and on other days for certain times. It is not always possible that medicines will be required just when the shop is open. There should be some special provision to ensure that the type of drugs and medicine required would be available when the chemist's shop is closed. The Minister said to us in Navan: "The doctors would be able to supply in certain circumstances." That may be but I can imagine a doctor writing a prescription and saying: "Take that to the chemist." If that happens at 11 o'clock on Sunday and the chemists close at 10 and Monday is a bank holiday it could mean that the person requiring the drugs or medicines would have to wait a considerable time. These are small details that could possibly be dealt with later but I think they should be brought to the Minister's notice now.
The Minister is aware of the question of cost. He says that reasonable arrangements are being made with the chemists regarding charges. At present we know that the difference between buying retail from a chemist and wholesale through a local authority can be as much as 46 per cent. It was 52 per cent. Taking the retail price as 100 per cent the wholesale cost would be 48 per cent. Now, I understand it is about 54 per cent. The retail charges I think are 100 per cent and the local authority can get supplies at 54 per cent. It means a very heavy additional charge unless these matters can be dealt with by the Department before the scheme goes into operation.
It is stated that the Minister will, by legislation, make regulations to fix different income limits for entitlement to general medical services. The Minister should have been more explicit and should have put in black and white exactly what he meant. At present the issue of medical cards is a joke—in some counties, a bad joke— and we all know of the person who says: "Is it not extraordinary? I am married, have £12 a week, three children and I pay 30/- rent and I have no medical card. My pal who works beside me has £18 a week, no family, a free house, or a house for 5/- a week, and he has a medical card. How did that happen?" Or he says: "He is well in with some politician." And he mentions the politician's name. He knows when he makes that complaint that neither I nor any other politician will say to somebody: "Mr. So-and-So should not have a medical card. I want the matter investigated." I will not do it. I do not know whether it is right or wrong. Certainly I have never done so and do not propose to do so. This position will remain until it is laid down in black and white so that everybody will know who is entitled to a medical card and so that when a person tells you his circumstances and complains about not having a medical card you are able to say: "Yes, you are entitled to a card," or, "No, you are not." Occasionally, you are able to do that now but in most cases you are not.
There is also the question of distribution under the Assistance Act which is referred to in the Bill as, apparently, a distinction is being made between the health authority and the public assistance authority. At present both are administered in most cases through the one office and come under one heading. I can see the greatest difficulty arising if the assistance sections and the health sections become separate and distinct organisations following the passing of this Bill. For instance, somebody receiving maternity treatment applies for a maternity allowance, or free milk. One comes under assistance and the other under health. At present the same officer investigates, if necessary, whether they are entitled to this or that. Under the proposed scheme it appears there will be duplication if not triplication in some cases. The Minister will appreciate that I am just taking this as I find it in various documents with which we have been supplied and from the information he gave us in Navan in October, 1966.
It was stated that better and more formal arrangements will be made so that the health authorities will assist persons in the middle-income group in obtaining drugs where undue expense arises. At present people in the middle-income group, at least in my own constituency, are reasonably looked after where the issue of drugs or medicines is necessary. On a number of occasions I have taken up the matter with the Minister or his predecessor and in both cases they were most helpful in trying to get this matter straightened out. If somebody was asked to pay for drugs or medicines and found he had to do so over a period and the cost was exceptionally high, the local authority was advised to provide supplies. A very informative circular was issued by the Department or the Minister some years ago which advised as to how and when this assistance could be given. If an improvement is being made, however, I welcome it.
It was proposed to make arrangements so that the district nursing service would become available free of charge to members of the middle-income group in respect of the homenursing of the aged and chronic sick. This does not appear to be made clear now in the Minister's statement. Perhaps he could not cover all these points. I have difficulty in finding the White Paper and I wonder if there has been some change in the proposals. It was proposed that provision would be made for a home help service in legislation and consideration was being given to the organisation of the service, including the role of voluntary organisations. Again, this is not mentioned in the Minister's speech; possibly it is somewhere in the Bill and I have not been able to dig it out. It is a long time since the White Paper was issued and a short time since the Bill itself was published.
The proposal to abolish charges for out-patient services is excellent. This was one of the most stupid things in the existing Health Act because it meant that people were deterred from going to hospital if they did not have the money. I fear the Government do not appreciate that there are still many people seeking out-patient services who have not 2s 6d or 7s 6d to trot out and who consider it an impost if they are asked to pay such a sum. On more than one occasion I have had to persuade somebody who had gone in for the service to go back again. He had been asked to pay and would not go again because not having the money readily available, he felt he was embarrassing somebody in seeking the service.
Another aspect of the matter which I think the Minister should be able to cover concerns out-patients. For instance, where I live on the east coast within six miles of Drogheda, Drogheda is easily accessible to the people of that area. Is it not ridiculous that if somebody wants an X-ray or a certain type of out-patient treatment which can readily be got in Drogheda, going there either by bus or bicycle, it is necessary to wait either for an ambulance to come 22, 23 or 24 miles from Navan to bring them to Navan, keep them there all day and bring them home again, or for a car or minibus to perform the service at a fairly high cost? Is it not ridiculous that these matters cannot be better organised and I ask the Minister, if he has not already arranged to remedy this position, to do so now. It should be possible for people to get attention at the nearest hospital. As somebody said yesterday, the object of the health services is to ensure that the patient gets the treatment needed with the least possible disturbance. Unfortunately, at present many people feel from their experience of the administrative side that that is not the object; that the object is to have a health service which they can say they are running in a certain way and the patient must do what he is asked to do whether it is good for him or whether he is able to do it or not. To avoid this, a very slight alteration should be included in this legislation, if it is not already provided for.
There is also a reference to the intention to have improved geriatric services developed by the new regional boards and to co-ordinate the work of all the voluntary bodies engaged in the care of the aged. Perhaps there is something in the Minister's brief about it.
The proposal to increase the maternity cash grant from £4 to £8 for each child and to have a further increase in respect of double or multiple births is a very good idea. Again, I do not agree with Deputy Ryan when he says that the money was spent in a certain way. I do not know enough about conditions to know if that is the position but I do know that in country areas where, very often, a child is born at home, the father must stay out of work to look after the other children and even to look after the mother and a man who loses his wages because of that will be very glad to receive the £8. He certainly will not have time to go to the local with it as most fathers at a time like that have enough to do without spending their time in the local.
In a speech which he made in Navan, the Minister said regarding dental services:
It is proposed to expand the present dental services so that there can be a fully effective treatment and follow-up service for the children and others now entitled to priority of treatment and to extend the services to make it available at charges to wholetime pupils of vocational and secondary schools in the middle income group generally.
Again, this appears to be left out of the Minister's speech. Perhaps there is a change of heart with regard to these things or maybe they are being put through in a different way. With regard to ophthalmic services, the Minister said:
It is proposed to extend the ophthalmic services and to make it available to the middle income group at charges not exceeding half the cost, the services to remain free of charge to classes at present eligible.
I should like some more information on that because it appears that charges are being retained in a certain way and either we are attempting to give people a service which is free up to a point or we are not and if we are not we should say so right out.
Coming back to dental services, may I again make an appeal to the Minister to see that some effort is made to do something about the number of dentists available. I am sure the Minister is aware of the fact that during the past number of years many dentists, as soon as they are qualified, go to England where, very often, they can get a junior partnership in a firm of dentists and pick up a very substantial amount of money. Perhaps it would not be possible to compete with that here but surely it would be possible to make some effort to ensure that dentists who qualify here remain here? An effort should be made, in fact, to bring some of our dentists home from England. I have been told by a doctor that bad teeth cause more illness than is realised. It is not just a case of the simple toothache and, indeed, many working days are lost because of the illnesses brought on by bad teeth. This would never happen if people had been able to obtain the right treatment at the beginning of the decay. I am sure the Minister is aware that in most local authorities there is a long waiting list for dental service and even then there is a selective service, and very often children and nursing and expectant mothers may have to wait much longer than anybody should expect them to wait.
With regard to the issuing of spectacles, I have had many complaints as I am sure the Minister has also had in his capacity as Minister for Health, about what is described as a racket in relation to this question. I would ask the Minister to try to ensure that this racket does not continue. I am told that some people are issued with frames that went out with the Battle of Clontarf.
When a person is obtaining spectacles he is shown the frames that go with them and, usually, the person will be horrified and ask if there is any hope of getting anything better. He will then be shown a selection and after he has made his choice he will be told that these frames will cost him another 30s. or, in some cases, up to £4 more. A person should be supplied with spectacles and frames that are acceptable to him. I do not think anybody should be asked to wear something like what one would see in a comic film.