Health Bill, 1969: Second Stage (Resumed).

Debate resumed on the following amendment:
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."—(Deputy Ryan.)

There is a very serious national problem in regard to drug addiction. The Minister for Health must stand indicted of refusing to accept the fact that drug addiction was a problem in Ireland. I remember three years ago bringing it to the attention of the Minister for Health and asking if a register of drug addicts could be compiled by the Department so that we would know the extent of the problem and so that we might arrange for the proper treatment of addicts. I recall that the Minister for Health at the time said "You are exaggerating the problem. I do not think what you suggest is good. I do not think it will help." He said it was not a serious problem and that setting up a committee to investigate it would not serve any purpose. The Minister and his Department have been proved wrong. Drug addiction is a problem. There are young people who are a serious problem in the community using any means to obtain the necessary drugs to satisfy their tremendous craving. Perhaps we are to blame for this but the problem does exist.

Notice taken that 20 Members were not present; House counted, and 20 Members being present,

We are faced with a very serious national problem. It was wrong that we should have permitted so much time to elapse before realising the position. Teenagers who are addicted to strong drugs face a life of ruin unless something is done immediately to rehabilitate them. I do not think the answer lies in admission to psychiatric hospitals because the normal psychiatric hospital cannot offer the facilities necessary for the proper treatment of drug addiction. We need special, trained personnel. It is wrong to admit addicts to general hospitals which cannot cope with their problem. Special centres must be made available. This was recommended in a report by Professor Ivor Browne of the Dublin Health Authority who said that special places would have to be provided for them in special centres. The Minister would be well advised to consider this as an emergency problem demanding immediate attention.

We will have to take special measures about the importation of drugs. There should be more control over distribution.

What drugs?

Drugs of addiction.

Is there not absolute control?

I am afraid there is not absolute control. I am afraid we are too lax about them. I am talking about importation by the wholesale chemists. I believe every doctor should have a narcotics number and there should be very stringent control exercised over the prescription of these drugs. In this way there would be some control over distribution. The present regulations are far from adequate as we can see. Remember, we are seeing the end product. We see people who have been able to obtain drugs very freely. Their dependence on the drugs has increased and they resort to every means to obtain them. These people were able to obtain drugs quite liberally when they were on small doses. Unfortunately, they need more and more as time goes on. There will have to be very stringent regulations governing the distribution of drugs. I would suggest something on the lines of a special narcotics code number for doctors in order that we could have this special control. There should be specially trained personnel in the centres.

We have to tell drug addicts that they can and will be helped, and that facilities are available for them. At the moment we are not offering them a helping hand, and that is a great pity. These people would gladly avail of assistance and treatment and we must make it known that they are available. They should be informed that drug treatment is available for them in small amounts while they are undergoing the withdrawal period from these strong drugs. Unless we face up to it and realise that the problem is there, we will never solve it. I earnestly urge the Minister to regard this problem as an emergency and to deal with it effectively, to make facilities available and make it known to drug addicts that they can and will be helped, that they are not criminals but victims.

We also have a serious problem that is generally overlooked because, as a nation, we are inclined to say that heavy drinking is a characteristic of this country and there is nothing wrong with it. Alcoholism is a serious problem, a problem to which we have devoted neither time, energy nor resources. Unfortunately, the alcoholic is often treated as a nuisance or a menace in society rather than as a patient suffering from a disease. The alcoholic is in need of help. I know one psychiatric hospital in which the normal charges for psychiatric patients do not obtain when an alcoholic is admitted. The charges go up. That is not right. It is unjust. The alcoholic is as much in need of attention and treatment as the schizophrenic, the manic depressive, or any of the other psychiatric cases one sees in mental hospitals.

I should like to see more and more money devoted to research into the problem of alcoholism which is receiving and has received very little attention from our health authorities. We have not had any survey or study of the extent of alcoholism in this country. Like many other things, we are inclined to overlook it.

Some time ago I heard of the number of burials which take place without death certificates being issued. That is a great reflection on the Department of Health. We are inclined to overlook these things and to say: "Yes, these burials take place, and these things happen, but we can do nothing about them." These are problems which should be tackled. We should adopt a very constructive approach to them.

I do not see anything in this Bill about the health centres operating a proper form of preventive medicine. The Minister's offer to the medical profession is geared towards curative and not preventive medicine. The Minister said not too long ago that he would like to see more attention being given to preventive medicine. Let him practise what he preaches. Let him encourage it, and not just say that we need more and more of it. Let him provide the incentives.

The excuse is given over and over again that we have not got the trained personnel to cope with a national cervical screening campaign. I will not dwell on the merits or demerits of such a programme. It is part of a public health programme which should be carried out by the Department of Health. Every assistance should be given towards the setting up of screening clinics. They have their place in helping to diagnose cases of early cancer. In the town of Kilkenny the public health clinic is able to run a cervical screening programme on a shoestring. I heard about it the other day. It is a wonderful thing. So far, quite a number of people have co-operated fully with them in operating it efficiently. The response from the public was particularly good, which shows that people are anxious to co-operate in public health programmes like this.

I should like to see public health centres like this operating in all our major towns so that we could in this way carry out a proper preventive medicine programme. I should like to see money devoted towards it. It can be done. It can be operated successfully. The Minister said they could not get a cytologist from the Dublin Corporation Health Authority. We could train technicians who could very readily and efficiently carry out this task. It is not necessary to have a cytologist in every centre. We could have good trained technicians. I discussed this with a pathologist of note and he believes it can be done and quite cheaply, and that we could have a very effective public health programme in operation.

While on the subject of health centres and public health, I see no mention in the Bill about the conversion of the dispensaries which are to be abolished. I should like to see them replaced by proper health centres which would provide the basic laboratory facilities which are at present made available to in-patients in hospitals. This could be done at the health centres and would help to reduce the cost of the health services. It could be done on an outpatient basis at these health centres. It would be simple to provide that specialists would be in attendance on special days. If we had this, we could ensure that all the necessary investigations were carried out before the patient was finally admitted to hospital. One can imagine the saving there would be in hospital charges if we initiated such a scheme. It should be possible to arrange for doctors to attend at health centres and to provide the service needed.

Those are some of the ways in which we could provide proper health services for our people at low cost. It is wrong for the Minister to say we cannot afford a national health scheme when he refuses to look into questions like this: how can we run a very efficient health scheme and provide proper services at low cost? We will have to look into the problem of our hospitals. We should remember that the hospitals are there to cater for the public, not the public to cater for them. Everything should be done in the interests of the patient. I should like to see visiting hours designed to suit the relatives and not to suit the administrative staff. This is important. The patient is a very important person. If this were borne in mind we might get a more modernised concept as to what is needed in hospitals.

I should like to see more information available to doctors about patients' reports. This is one thing that has gone wrong with our system. Doctors cannot get reports in time because the Minister and the Department refused to provide money for secretarial personnel in hospitals. When I was in practice I saw cases where I could not get a report for weeks. The relatives came and told me what had happened. In one case the patient had died and that was the first I heard about it. Within three or four weeks I would hear from the hospital and when I complained I was told the Department refused to provide money for secretarial personnel in hospitals and that the medical staff could not cope with the situation without this. We are living in an age when all this must be streamlined and a proper service provided.

I see no mention in the Bill of what we intend to do for our aged. I should like to see geriatrics become an important aspect of general hospital care. I do not think we should set up geriatric hospitals. Geriatrics should be part of the general hospital service. I should like to see geriatricians appointed. We have not many of them, because the care of the aged is always relegated to second or third place. Geriatrics is a specialised subject, and more can be done for the aged if we have the expert personnel to deal with them.

I should like to see psychiatry as part of the general hospital service. There is no mention of this in the Bill. We talk about psychiatric hospitals but psychiatry should be based on the general hospital system. In that way we shall alter people's views on psychiatric problems and make these problems as normal as other physical ailments. A stigma still attaches to psychiatric illness, and we are per-petuating this by keeping psychiatric hospitals apart from the general hospitals. If psychiatric treatment were given in general hospitals, there would be greater co-ordination between medical, surgical and psychiatric personnel, and this is in the interests of medicine and of the patient.

I do not see any reference to the arrangements for a marked increase in the number of domiciliary nurses who can follow up cases discharged from hospitals. I know of a man who was discharged recently from a mental hospital in Dublin and was found dead on the side of the road. It is not good enough to discharge these patients without having social workers and domiciliary nurses to call on them. There is no use in placing a person back in the community unless the proper personnel are available to follow up their cases.

There should be adequate facilities for the treatment of long-term patients. Perhaps arrangements could be made whereby these patients would be treated at special centres, not necessarily hospital centres. There is no provision for this, and we must alter the outlook of the Department and of the medical profession on it. At present these long-term patients take up a great number of beds in our hospitals. In Dublin city there are only two places for the chronically ill or the incurable. Chronically ill patients very commonly need, not medical treatment, but nursing care. It is not right to inflict them on their families who cannot provide facilities for them and who are not trained to deal with these problems. These are specialised nursing problems. Proper centres will have to be provided for them where needed.

The Minister has boasted that we are doing a tremendous amount for our mentally handicapped. I wonder if we really are. It is very easy to say we have provided so many beds compared with 1932. That is not a realistic comparison. This problem was neglected for years. Many of these patients in their teens, in their twenties and thirties, were on the waiting lists of institutions for many years, from the age of five or six, but were never admitted because there were no places for them. They were left to their parents who sacrificed everything to try and keep them. A grave injustice has been done to those people and to their parents. The State should have done something for them but refused to recognise its responsibility. Earlier this evening I spoke to a lady who has a son of 33 physically handicapped since 16 years as a result of tubercular meningitis. He was never properly trained for anything. He has made numerous attempts to commit suicide because he has had nothing to occupy his mind. As a result he is now in a mental hospital. It is an indictment of our system and of our State that we have done nothing for these people.

Better facilities for our nurses should be incorporated in this Bill. Our nurses are still awaiting the 11th round increase, which is due since April, 1968. It is a shame that these dedicated girls, who do such Trojan work, should be neglected as they are. Because of their dedication perhaps they do not fight their cause enough. The demand for Irish nurses in the United States and in Britain is tremendous. Unless proper salary scales are introduced for them very soon we may not be able to bring in any Health Bill because we shall have no nurses in this country. There are tremendous attractions abroad for nurses, and the great pity is that although trained in this country they must go abroad to get proper remuneration for their services. I would say to the Minister in all seriousness that we shall have a great shortage of nurses in this country in the near future.

We complain that we have not enough nurses. In many cases this is due to the fact that sufficient nurses cannot be accommodated in the living quarters of our hospitals, in nurses' homes. There is a ready and a simple solution to this, that the nurses live out. I do not see why they should live in these homes. If we are to solve our nursing problem, which is a big one and getting bigger, we must find a constructive solution to it, that is, to allow our nurses to live out and also to abolish this idea of nurses paying fees. The sooner this is abolished the better. It serves no useful purpose. Its only effect is to prevent the dedicated girl obtaining a place in a nursing school simply because she has not the necessary fee. This is wrong. It is unjust. It is an indictment of the system. I ask the Minister to look into this problem to see what can be done about it now and not wait until the problem becomes so acute as to be wellnigh incapable of solution. It takes years to train a nurse. Fees should be abolished and nurses should be allowed to live out.

Nurses can live out.

Student nurses cannot.

If the Deputy's daughter came up from the country to be a student nurse the Deputy might not be anxious for her to live out.

Young civil servants up from the country live out. I do not see that student nurses are any different. Nurses are treated abominably from the point of view of remuneration. It is very important that there should be equality of pay in psychiatric nursing in particular. The female nurses do exactly the same work and work the same number of hours as their male colleagues, but they are paid less than their male colleagues. At the moment the greatest shortage of nursing personnel occurs in psychiatric medicine. I appeal to the Minister to look into this matter of equality of pay for these nurses.

The Minister should give attention —he has ignored this matter up to now —to health centres. If we had properly organised health centres people could be informed of that to which they are entitled as of right instead of going around looking for information, as they are compelled to do at present. Many people have paid for hospitalisation not realising that they were entitled to avail of health services. That should not be permitted to continue. All the information necessary should be available immediately to people seeking it.

There is nothing in this Bill about medical training. It is an important matter. If we are to have good family medicine we will have to have proper training for our medical students. It might be a good idea to have these students attached to health centres where they could familiarise themselves with health problems and family medicine. Doctors in general practice are constantly faced with patients needing psychiatric treatment. Too many doctors are ill-equipped to deal with such patients. We should also have more psychiatrists attached to our prison service.

The Minister must come forward with an alternative method of financing health services. He promised to consider an alternative method. He did say he was investigating the matter, but he has not come forward with any alternative suggestion. People generally are dissatisfied because of the high incidence of health costs on the rates. The decision of Dublin Corporation last night is to be commended. The rates cannot bear the cost of health services any longer. Central taxation will have to shoulder the burden in future.

It is important to consider what will happen in the interim period between the passing of this Bill and its implementation. There was provision in the 1953 Act for aural, opthalmic and other services for those in the middle-income group but enabling legislation was never introduced. In fact, it is being introduced only now. In the interim will the dispensary service become more disorganised still? It is in a deplorable state at the moment. If a dispensary doctor takes a weekend off he has to try to run two practices the following week. As one doctor said to me: "It is like a bus driver who takes a weekend off and he is then asked to drive two buses the next weekend." The Minister for Finance was said to have agreed to the half-million necessary to pay for locums. The money was never forthcoming and doctors now have to provide locums at their own expense. If the money had been forthcoming a proper dispensary service would have been available all the time for the benefit of the people needing it.

The Minister must make up his mind that he has got to come to an early agreement with the doctors about the method of payment to them, keeping uppermost in his mind the fact that doctors do not want the present very considerable hospitalisation costs. These are the biggest item in the health services at the moment. The Minister will have to agree to a scheme which will uphold the dignity of the patient from the point of view of the doctor of his choice and the service he wants. The Minister's ambition should be to give doctors every opportunity of practising good medicine in the interest of their patients and of keeping the patients as much as possible out of hospital. Admission to hospital should always be the last resort and, where there is need for investigation, only if every considerable investigation possible has been done outside. These are points he must keep in mind in his plans to reach agreement with the doctors. The time for silence and secrecy about these negotiations is over. He should be forthright about them. I can see no reason for discussions in private. Certainly, I do not think that, if they are carried out publicly, without this veil of secrecy, it will do harm. I do not see what harm it could do. I think it was used purely for political purposes. Certainly, there are political motives behind the plan to hold them in private.

Finally, the Minister gives us a draft of his proposals. Despite all his talk with the doctors about keeping it private, he is very quick to send copies of his proposals to the national newspapers. Because of this, I should like to see the negotiations carried out without this veil of secrecy any longer.

If there is to be an interim period between the passing of the Bill and its implementation, I would ask the Minister to see to it that extra doctors are appointed to our dispensary system in order to try to make our dispensary service operate satisfactorily in the interests of the patients who are suffering terrible injustice under the present scheme. For his own edification, the Minister should visit some of the dispensaries in Dublin city. I can assure him he would be enlightened and would certainly appreciate my way of thinking on these matters.

It is not enough to say that we will pass legislation. We should ask ourselves what we can do immediately and effectively to help those people who are in need, who are ill, and who are attending dispensaries and enduring terrible indignities and humiliations.

The Minister should seriously consider and tell us what progress he has made in seeking alternative methods of financing the health service. I think he has a duty to tell us this in view of the dissatisfaction of the public with present arrangements. On that note, and with an assurance to the Minister that we will not oppose any measure that will help the people in need of medical attention, I shall conclude my remarks. We shall not oppose any measure that will improve the lot of our people. We shall strive at all times to further the interests of our people.

I should like to say, first, for the enlightenment of the honourable Deputy, that there are up-to-date health centres under the Dublin Health Authority. As recently as today, we opened another one, to add to the many that have already been opened. With the co-operation of the Minister and the Dublin Health Authority, great advances have been made in the erection, equipment and staffing of up-to-date centres in the city and county of Dublin and in Dún Laoghaire. I do not know of any patient or of any case within the jurisdiction of the Dublin Health Authority who has suffered by reason of neglect or refusal of treatment. If there are any such cases, they must go only to Deputy O'Connell because nobody has come to me——

The Deputy is not a doctor.

I am a public man. In that capacity I have to do a lot of jobs—solicitors, doctors, priests and so on.

I shall report the Deputy if he is not careful and have him prosecuted.

He is a Jack of all trades.

We have a number of jobs that we must do as public representatives. It is alleged that no advice is given in our health centres. A number of social workers are appointed to our health centres. There are health nurses who are specially trained to meet the various patients that will come there. There are the staffs of doctors and if a doctor is not to be found in the health centre he will always be found at his private residence. I want to be factual about this matter.

One would expect Deputy O'Connell, a doctor, to be practical and not to present the House with a number of untruths. Since it was created in 1960, the Dublin Health Authority has been very efficient. It has done wonderful work in organising the hospitals and health centres and in the appointment of social welfare officers and doctors. Doctors who are trained for that type of work are given certain jobs. To listen to Deputy O'Connell, one would think that nobody was doing anything and that those of us who had anything to do with the administration of hospitals were a heartless crew. To listen to him, one would think that all we had to do was to raise our hands and that money would fall into them. Criticism is valuable but I abhor a misrepresentation of facts.

We have given particular attention to the health centres. We have welfare clinics with special nurses. We have social welfare workers, also. I want to defend the authority of which I am a member and to defend, also, the Department of Health who have cooperated with us in every way possible. Naturally, one would like to see more achieved but great strides have been taken in our hospitals in the past eight or nine years. The general hospitals, as well as psychiatric hospitals, have been modernised. General illnesses and psychiatric illnesses as well as dentistry are catered for. There is an up-to-date dental unit in the new clinic which was opened today at Limekiln Lane. To listen to Deputy O'Connell, one would think that our Government had no consideration for human beings. It is sad to hear such talk from an educated man, a man who is himself a doctor.

Deputy O'Connell referred to drugs. I remember that people were taking drugs years and years ago and that position will continue to the end of time. Recently, there has been a drug scare. There have been 29 admissions to a psychiatric hospital in this city, most of whom are men.

The Dublin Health Authority has been doing all they can to look after the aged. With the co-operation of their very efficient medical staff they have set a centre aside for this work, work which is not at all easy. Deputies on the opposite side have been saying that it is easy to get drugs in retail and wholesale chemist shops. They are completely wrong. I will not say anything about people coming in from other countries to pedal drugs, to sell them in dancehalls, because the Department of Justice are dealing with it. The Minister for Health has set up a special committee to deal with that problem. The Dublin Health Authority have set aside ten special beds in a unit which they have called St. Enda's. In it we hope to give specialised treatment in an effort to cure drug addicts. That work will go on. We are meeting this problem as it arises.

It is easy for Deputies to talk about what should be done for old people. In earlier days nobody could go to a hospital unless he was dying. Today the whole trend has changed. Relatives of elderly people are afraid to go out and leave them in the home without anybody to look after them. Because of this concern increasing numbers of old people have been coming into the various homes provided by the Dublin Health Authority. The general hospitals will not keep them unless they suffer from acute illnesses and they would be on the road if the health authority did not provide for them.

This treatment of the aged is a huge problem, as my colleague across the House, who is chairman of the Dublin Health Authority, will appreciate. Day after day we get letters and telephone calls asking us to get so-and-so into hospital, with the result that our hospitals are becoming overcrowded. We have provided a number of units for the aged, including those in the Connolly Memorial Hospital in a section which formerly was used for tuberculosis patients. TB is now a disease peculiar to people aged between 50 and 70 who had earlier suffered from such chest illnesses as asthma and bronchitis.

It is unfair, therefore, to blame the Dublin Health Authority, the Department of Health and the Minister. All of us are trying to do our best to remedy a huge problem. The Dublin Health Authority have set up a welfare branch to look after old people and today we opened an old folks' club in the Coombe to care for elderly people in that area. Many of the people availing of this service come in suffering from malnutrition, having neglected themselves while living alone.

I should like to take this opportunity of thanking the voluntary organisations for the work they are doing in this matter. For instance, the Meals on Wheels scheme has been bringing midday meals to those who are unable to attend the centres provided by the authorities. The club opened in the Coombe today is second to none. We have tried to make it as comfortable as possible. However, the problem of caring for the aged is growing from day to day. It is a problem in which I am especially interested. This evening I got a telephone call from a man in County Dublin asking me if I could get his father into hospital. The doctor attending him told him that there was a big waiting list. This situation occurs day after day, week after week, throughout Dublin city and county.

I should like to see efforts being made to provide care for the aged more by means of home help, thus allowing sons, daughters and daughters-in-law to look after their parents at home. It is much more economical to give younger relatives £5 or £6 a week, to help compensate for their inability to go out to work where there are old people to be looked after, than to send these old people to hospitals or other institutions at a cost of between £15 and £20 a week.

Another problem we are trying to deal with is that our elderly hospital patients are living longer. In St. Kevin's Hospital, for instance, when I was chairman of the Dublin Health Authority we had three people who celebrated their centenaries. I suppose Deputy Ryan has the same story to tell about the present time. The problem is becoming greater despite the tremendous help being given by social workers and religious organisations.

Deputy O'Connell complained that patients discharged from psychiatric hospitals are never followed up afterwards by social workers. One of the primary concerns of the Dublin Health Authority is to provide social workers to go to the homes of such people to try to rehabilitate them and to train them to be useful citizens outside. Great advances are being made in this work. The same Deputy said that such patients have died on the roads. People have died on the roads and people have died in this Dáil but general statements of that kind do no good and are aimed at discrediting the medical profession, the health authorities and the Department. I can only conclude that the man who made that statement did so in ignorance otherwise he would not have made the statement.

In regard to the prison service, cases are sent through the courts to a psychiatric doctor for examination. We have special co-ordinating machinery operating between the Department of Justice, the courts and the hospital service. The training of nurses and doctors for this type of specialised treatment is advancing daily. The Department of Health have helped us considerably as have various Ministers for Health, including the present Minister. I hope this development will continue and that we will be able to continue to help these people in every way possible

Another matter to which I should like to refer is the problem, which I am sure has been encountered by other public men, of middle class people who through illness in the family or a death in the family are going hungry but who will not tell anybody about it. In the Dublin Health Authority we set up a special social welfare department some years ago. We are anxious to ensure that no member of our society will go hungry. Some people are only too anxious to make representations for themselves but there are others who would sooner die than let anybody know they have not enough money to feed themselves. I want to avail of this opportunity of thanking the people in our social welfare department for the work they have done in this regard. They have done it effectively, not only from a charitable point of view but from an administrative point of view. We are only doing what we should do in having such a department. I welcome this Bill particularly because when it becomes law the costs of additional medical services will be borne by the Department of Health.

That is not in Bill. It is in the White Paper.

It is implied in the Bill.

It is not. It is 50 per cent, the same as Dublin Corporation voted against last night.

I welcome the provision in the Bill regarding the choice of doctor. With regard to the various working parties, this is a big task for public men and for the doctors and hospitals. I happen to be on a few working parties co-ordinating the work of various hospitals and I must say our progress has been very slow. The federated hospitals have been holding meetings for a long time and have been very slow to reach a decision. Quite a few members of the Dublin Health Authority are on that body and they are doing their very best. Public men have a more practical grasp of things. We have no axe to grind except to provide the people with the best medical service we can give them. We support any advances that have been made in our time for the betterment of our people, but we come up against a great deal of frustration.

I am glad the Minister has made it clear that 50 per cent of the members of these regional boards will have to be public men. I would nearly suggest that it should be 51 per cent, but I do not want to be quibbling. Deputy Ryan and myself were on a working party which dealt with the Mater Hospital, the Richmond Hospital, Jervis Street Hospital and the Dublin Health Authority and we had many meetings trying to resolve how many members would be from the health authority and how many from the hospitals. No matter what our political views are, we are most anxious to cooperate and to provide specialised hospitals.

The Minister has a tremendous task and I do not envy him. The operation of hospitals is costing a lot of money and one hospital is competing against another. We have specialised hospitals dealing with such things as cancer and, of course, all hospitals have carried out successful operations for cancer, tuberculosis and other problems. There is need, however, for a specialised hospital to deal with heart operations. There is a lot of overlapping in the small hospitals which results in great expense for the Department. The greatest demands are from the voluntary hospitals and each year the capitation grant is going up. They cannot help that. However, as far as the Department is concerned, it is a big drag.

We have reached the stage where people are looking for more specialised treatment. We also have to consider the number of people kept out of hospital as a result of the specialised treatment they get in the health clinics. I am delighted to see in the Bill that provision is made for increasing the maternity allowance. That will be welcomed by young married people. Another advance is that children can now be treated before going to school. A big problem in Dublin and with health authorities generally is the dispensing of drugs to the various health centres. The dispensing of drugs is as well controlled as it can be by those responsible. The provision in the Bill whereby there will be consultation between the Department of Health and the local authority in an area to see that drugs will be given more cheaply, possibly at wholesale prices, so that they will not be too expensive, is welcome. These are our problems day after day. The advances made in the Bill are very welcome.

The previous speaker referred to a free health service. We should all like to see that, but I should like to know how it could be financed, seeing that it would cost another £50 million or £60 million or possibly £100 million a year. We cannot get money from any source but the people: if they do not pay for it in the rates it will have to come from taxation. But, as soon as a Government increase taxation to provide for this service, the Opposition will vote against the increase. We must be practical and factual. The idea of a voluntary service has been considered. Many of us are members of the Voluntary Health Insurance scheme; many who can afford it do not bother; and there are others who cannot afford it. However, if it could be arranged that every citizen would contribute some small sum towards the health services, it would relieve taxpayers and ratepayers to a considerable extent. The whole trend today is to depend more on State control, but if the Minister were St. Peter himself he could not get more money.

Last night a certain decision was made by Dublin Corporation. I do not agree with that decision. I, along with other members of the Dublin Health Authority, went on deputations to the Minister for Health, who received us most courteously. He went as far as he could, when he met the first deputation, and gave us £350,000 towards our social welfare section. I do not know how he fared afterwards with the Minister for Finance. Everybody must realise that, from a Party point of view if we were able to give another £50 million towards health services, especially in an election year, we would be fools in Fianna Fáil if we did not give it. Some people outside think we have it and will not give it. But we are all politicians and we want to see our Party giving as much as possible so as to make it easy for us to get back here again. We were never a Party to attempt to make the people pay exorbitant rates, but we must be practical. We made representations and did our best to get all we could from the Department of Health, the Taoiseach, the Minister for Local Government and the Minister for Finance. We failed because the Minister for Finance had no more money to give.

Not even for a bag of cement.

When the Deputy's Party was in office there was not even the price of a bag of cement. I am delighted the Deputy reminded me.

I have read the Fitzgerald Report and I have found parts of it practical and other parts of it not so practical. I suppose everything is good until you try to put in into practice, but you find the flaws when you try to administer it. In Dublin we are deeply concerned about all the hospitals we have and the various treatments afforded. I can speak highly of the dispensary service, the doctors and nurses and the general practitioners. They are all doing a very good job and are most charitable people. Yet, the co-ordination of hospital services is long overdue. Anything we can do as public men we shall do it in an effort to give our people the very best and most modern treatment. Even in the United States there is the same problem of soaring hospital expenses. They are also trying to co-ordinate hospital services. In our case it is a necessity. When we built regional tuberculosis hospitals we were able to give specialised treatment and now, thank God, very few young people are suffering from TB. Only people advanced in years are now affected, according to what our chief medical officer has told us.

Cancer is another big problem and anything that can be done to save our people from that dreadful scourge will, I am sure, be done. Both St. Luke's and Hume Street Hospitals are doing excellent work. Again, this is a case of specialised treatment and early diagnosis. We hope that medical research will succeed in producing a cure for cancer. Many years ago it was found possible to cure external cancer. Even an old woman in the Minister's locality had a cure for cancer of the lip in my young days. Provided the infection was external much good could be done, but in regard to certain aspects of the disease there have not been very big advances except in cases of early diagnosis and treatment.

I wish the Minister luck with this Bill. I have only spoken generally about the matters which concern us, without going into detail. I hope when this measure is in operation it will be found to meet with general approval and be a help to all concerned. The prospect of a free-for-all service is something that must await consideration as a separate item. We must see exactly what we want and what increased taxation would be involved. Who will say we should impose it in order to provide such services? When we reach that stage and when people shoulder their responsibilities instead of running away from them, only then can we hope to provide a free-for-all health service.

The Minister, in the concluding paragraph of his statement, said that the Bill was a highly technical document and that he was presenting it to the House as offering what the Government consider the most rational solution to a number of the problems which arise. Stripped of its superfluous phraseology, this Bill offers little or nothing, despite what the Right Honourable Member from County Dublin has been telling us during the past hour.

In the first instance, let us examine the advantages of the Bill if they may be so termed. The main one is the choice of doctor but it was not necessary to have a new Bill to bring in that type of regulation. That could have been embodied in the health legislation as it exists at present. We are told that the maternity cash grant is to be increased from £4 to £8 and there is something in another section of the Bill about improvements in the supply of drugs.

In making a factual appraisal of this measure these are all the advantages to be found but what about the debit side? This Bill, in my opinion, sounds the death knell of the local representative and we all know the tradition of the local representative in this country. We know the work done by local representatives down through the years, both under the British system of government and under the Irish system since it was established. Here, we have a Novotny style Bill which might have been drafted by the man who has taken over Czechoslovakia. It is a Bill which takes all power from the local authorities.

Let us examine the Bill in detail and see what is happening. First of all, let us address ourselves to the burning question of the hour—the difficulties and problems that have arisen in part of this country because of the local government representation and the system of local government voting. The people of that part of the country believe that they are denied the right of fair representation on local authorities through the unfair voting system.

The Deputy is getting away from the Bill before the House.

I shall relate my remarks to the Bill. In this measure known as the Health Bill, 1969, the powers of the local people through their local representatives are being filched from them by the Minister for Health with the connivance of his Government.

I know very well, as do many others, that people of a professional type such as the Minister is, have always been opposed to the local representatives. I am entirely against the administrative provisions of this Bill. I am a firm believer in local democracy and, as I have said, this Bill is filching the rights the ordinary individual has through his elected local representatives.

Health boards are to have a 50 per cent public representation and, as mentioned by Deputy Ryan, it is reasonable to assume that a percentage of that percentage will be Fianna Fáil people. The Minister will appoint his own henchmen. I do not know what qualifications such appointees should hold but, possibly, it would be an advantage to potential applicants to become members of the well-known Fianna Fáil organisation, the Taca group.

We are told that in the first instance the Minister will elect the representatives from the medical profession and that later on, according to the Bill, they will be given that power themselves. Even a body constituted on that basis is not empowered to appoint a chairman or a vice-chairman. The Minister for Health reserves that right for himself. The Minister, according to the Bill, will appoint 50 per cent of the members of the hospital boards. Bureaucracy is taking over here. We are leaning heavily on the system that is operating in eastern Europe at the present time and, as I said at the outset, this Bill is the kind of measure one would expect from the parliaments of countries where democracy does not exist.

The executive functions of a health board will be carried out by the chief executive officer. In all applications for services of any kind under the Act, the board members will have no say whatsoever. The Minister specifically mentions that it is not in order for any member of the board to bring to the notice of the board any individual grievance. Therefore, an aggrieved person who, at the present time, could approach his local councillor, will have no business whatsoever in approaching the councillor when this Bill becomes law because this Bill gives the absolute right of bringing forward grievances to the chief executive officer.

Is that what the Minister's Party term democracy? This Bill has been produced by the legal profession who, as I have said, have never been favourably disposed towards local authorities and local representatives. I wish to speak as forcibly and as vehemently as I can tonight against this move to deprive the people of the services of their local representatives. It is all right for the Minister to say: "Your rights are set down in the Bill". It is all right for some Deputies we have listened to recently to say: "All those services are available to you by legislation. All you have to do when you require them is to make application and everything will be in order". As everyone here knows, that is not the case. How many times have local councillors had to intervene on behalf of applicants denied services, possibly because in some cases they failed to mention certain factors? Does the Minister now say that that should no longer be the case? Do the legal profession not earn their living by making representations in court and by bringing forward factors in support of whatever case their clients have? Do the people not bring their grievances to their local representatives? Under this Bill all good county councillors, corporation members and others are to be deprived of that right.

What about the number of members who will get on the new boards? We have no indication of the size of the proposed boards. It is all to be done by regulation. This Bill is a mass of proposals set down in general terms to be implemented later by Ministerial regulations. Nothing is spelled out. It is left to the Minister, if and when this Bill is passed, to make regulations suitable to himself. The point I have been making is that we are moving away from democracy. We are moving away from the system we have known in the past, the system whereby local people go forward, offer themselves for election and after election have a say in the management of local affairs.

Up to the present health matters could be said to take up at least one-third of the work of local representatives. Now the Minister for Health is removing this from them. Perhaps it will not be too long until they decide to take matters concerning roads and housing away from the local representatives. Eventually, local authorities will disappear. If the Government were to say frankly: "Look here, we think local representatives have got to go. We propose to run everything from a central body and there will be no need for local representatives for the future" then at least they would be honest about it. But under this system they are doing it in a subtle way.

I want to draw the attention of Deputies and of the general public to this matter. Who could approach the Minister in relation to this type of grievance? If the Ceann Comhairle had a grievance concerning one of his constituents in Donegal is it not to the local county council he would go? Would he not go to the local people on the board? Would he be likely to go to anyone else? Everyone knows it is to the local councillor the people go. Democracy sets down that representatives must be elected by the free vote of the people. When you put persons on a board without having been elected by the people, you are departing from democracy. Such persons have not to go before the public and give an account of their stewardship. In this measure you are giving majority rights in regard to health in the future to persons who have not been elected by the people. This matter cannot be over emphasised. I am making the case that to a large extent the question of civil rights enters into this, just as much as it enters into the Northern Ireland question at present.

We are discussing the Health Bill and civil rights in Northern Ireland have nothing to do with it.

The administration of the Health Bill and what will happen if the Bill becomes law is what I am discussing. Deputy Carter may laugh.

I am not laughing.

I do not know whether Deputy Carter's views are in favour of or against the disappearance of the local representatives and the taking over of the health services in the dictatorial manner proposed in this Bill. I feel this is not a good day's work. I feel it is reminiscent of what is happening in countries where democracy no longer exists. As I mentioned at the outset, this is a piece of legislation which would be more suitable to such Parliaments than to the Parliament of a free democratic country.

What is likely to ensue from this power which the Minister will be given through the health board and through the hospital board? Looking at this book Outline of the Future of the Hospital System we find proposals made by eminent men, but eminent men who are not sufficiently close to rural Ireland to know the problems confronting the people there. Yet we can see these proposals being put into operation by Ministerial regulation when this measure is passed. When it becomes law he will have power, through his 50 per cent membership on the hospital boards and through his henchmen who will be appointed on the other side, to do exactly as he wants and not act in a democratic way.

In regard to hospital boards, surely a representative who gets a gift of that post from the Minister will not criticise the Minister? While he is a member of a health board or a hospital board will he say the Minister is wrong? There is no question of his saying so. He will be there by virtue of the Minister appointing him and he will be a yes-man. He will not contribute anything towards the board except to do as the Minister will dictate.

Will the Deputy not admit that the boards will be statutory bodies?

I am dealing with the membership of the boards as proposed under this Bill. For Deputy Carter's information the Bill states that the Minister will appoint 50 per cent of the membership. Half the board will be appointed by the Minister. One can see then what kind of board it will be. We are moving over now to the autocratic system; we are moving away from democracy. That is what I have endeavoured to point out during the last ten or 15 minutes.

Let us examine some of the results that may arise from this dictatorial system that it is proposed to implement through this piece of legislation. Let us take the county hospitals that are to be wiped out or demoted or downgraded according to this report to, I think the official term is, "rest homes" or convalescent homes. What will happen now to Bantry Hospital in my constituency? Is it likely that the hospital board will vote against the Minister's proposal? On 14th December last in this House the Minister said he accepted, in principle, this report to downgrade hospitals. I have been a public representative for more than 20 years. Before I became a member of Cork County Council there was agitaton for a county hospital in west Cork. That agitation persisted and seven years ago the hospital was opened at Bantry. Now the Minister will be closing or downgrading the hospital that has served the people of the area very well indeed. They are very satisfied with it and I challenge the Minister to come to any part of south-west Cork, even the part most favourably disposed towards his Party, and argue the case with me so far as the provisions in this Bill are concerned and particularly those which will wipe out or downgrade hospitals such as Bantry. Bantry is not only one of course. There are other hospitals throughout the country. There are a number in the midlands; there is a hospital in north Cork, Mallow, which I understand served the people of that area very well.

There is one in Longford.

There is another at Mullingar. This is a big question. This hospital in Bantry could be called a newly-opened hospital. It has new equipment and an excellent staff who are giving satisfaction. When it satisfies the people, I do not see what else is needed. Fortunately we have little or no complaints so far as treatment in that hospital is concerned. This Bill deprives the local representative of any worthwhile say in ensuring that Bantry Hospital will maintain its present standard never mind being upgraded.

However, it could be said—to use a term that may not be parliamentary— that Fianna Fáil have been a bit cocky of late. They think they cannot be replaced. They have the feeling that they will be over there for an indefinite period of time. As a result they want to assume the mantle of dictatorship. Some of the Ministers have been there for a relatively long period and they are becoming stale and arrogant.

We are dealing with one Minister now, the Minister for Health.

With due respect to you, Sir, you may have heard— I am sure you did—of the collective responsibility of Government. Fianna Fáil tell us that all measures put through this House are the collective responsibility of the Government. Even though it is the function of a particular Minister, in this case the Minister for Health, to outline the Bill to the House, to listen to the discussion, reply to the debate and to pilot the Bill in its passage through the House, it is not his measure. If we accept Fianna Fáil doctrine, it is a Government measure. On that basis I am justified in referring to the Government in general.

No. The Minister for Health is responsible for the measure before the House.

I mentioned a while ago one of the most important functions of any health authority, that is, to deal with individual applications for medical cards, for hospitalisation or for dental, opthalmic or other services. I want to emphasise again the dictatorial attitude behind a Bill in which it is provided that it will not be justifiable for any member of a health board, a hospital board or a committee established under the Bill to make reference to any individual application. That is so important that I must find where it is contained here and read it out for your enlightenment, Sir, and show you what it is the Minister for Health is trying to get through the House. I shall read from the Explanatory Memorandum to support the point I am making——

Did the Deputy find it?

——about what is going to happen when this measure becomes law so far as individual applications are concerned. It reads:

However, where, under the new Act or otherwise, a specific statutory function is given to the chief executive officer, the board and its committees will not be empowered to take decisions or to issue directions to him about the discharge of that function.

They cannot issue directions to him. He will be some kind of infallible person.

In general, the functions on which the board will be limited in this way will relate to decisions on cases—such as eligibility for services or on the supervision of staff.

The supervision of staff and the provision of services—they cannot direct him on that. All power is being withdrawn. It has been filched in this Bill. The position is much worse indeed than it is now in another part of the country where they are speaking about the voting system in local elections. Will Members of Dáil Éireann—granted members of the Minister's Party must answer yes—be satisfied? Are there any Fianna Fáil TDs who are not satisfied with this position? Are they satisfied to give bureaucracy this power, to deprive those who have to be elected by the people of any say? Here in the city of Dublin, with its more than 600,000 people, many of whom must avail of health services, as in other parts of the country, once this measure becomes law it will be useless for a person to go to any councillor with a grievance because the councillor is being deprived of any right or any say under this measure.

Let us examine and think over another chapter of the Minister's statement. He states: "You have power to appeal against the decision if you are not satisfied with it." The chief executive officer is supposed to be the man who will make the decisions except when he delegates power to other officers. The Minister tells us: "If the chief executive officer were to refuse Mary Murphy's application for dental services, or to refuse her application for a medical card, she can appeal and her appeal will be determined by another officer of the board." Here is a funny situation. I am sure Dublin Opinion could base a useful cartoon on it. When you make an application to one man in the office, one executive officer hears it and turns it down, according to the Minister he will then nominate some other officer of the Board to determine that appeal. Do we not know well what will happen? What will happen is that one officer will say the other man was wrong. He will in my hat. This is nonsense of a high order. It is the type of nonsense we have been getting from that stale, arrogant crowd over there, the Fianna Fáil Government.

Who says this will improve the health services? Where are the improvements for the person who is sick, the person who is lame, the person who is blind or the person suffering from any ailment? Where are the improvements? They are meaningless improvements so far as that section of our people are concerned. We hear a lot of talk about our elderly folk. I know very well that the elderly people present a big problem. In this country, possibly more so than in other countries, unfortunately, a sizeable percentage of our population is in the over-70 age group. Many of them have to receive institutional care. I was attempting to solve that problem myself in a proposal I made to the health authority in Cork, which, however, did not see it through. I said that an obligation rested on public funds to help those of our people who through physical or mental illness cannot provide for themselves, with particular reference to our elderly and incapacitated people, such as bedridden men and women, and unfortunately we have a big number of them in the country.

I suggested that they should be entitled to apply for and get a disablement allowance when their right to it was determined by the appropriate authority. Apparently our county manager said that should not be the case, even though it was provided for under the 1953 Health Act. I forced the issue in Cork and 40 members of the health authority supported me originally that this was sound commonsense and that it would help to relieve the burden on public funds but, when it came to the final stage, I regret to say that that support did not exist except in a small way.

Let us examine the case in support of my argument. If John Murphy is 70 years today and he has 100 cows, if he assigns the farm to his son and keeps not more than £50 for himself and his wife, he is entitled under our regulations to a non-contributory pension of £3 5s per week. That is what the law of the land allows him. I do not disagree because I can see that with our social welfare code it is not possible to differentiate between a person with that type of means and an old lady living in wretched conditions in a hovel. All she gets is £3 5s a week also. I claim, therefore, that the health authority should help her. That was my proposal and I fought for it over a number of years at meetings of the Cork Health Authority, with a view to getting payment of allowances to people who resided with incapacitated people or neighbours who helped them and cared for them in their own homes. It would then be the obligation of the health authority to come in and help.

I listened to Deputy Burke telling us about the number of homes he has visited during his public life. I have no doubt that he has visited many. I am sure that he found what I found on all occasions that, irrespective of what the county home is called, whether it be St. Charles' or anything else, the people are not satisfied. The old people in the homes I visited would much prefer to be in their own neighbourhood living out the winter of their lives amongst the people with whom they were brought up. They would be much happier and much more contented if they got a disablement allowance of £3 7s 6d a week to supplement their old age pension. Would not this be cheaper and better than the present position where in some district hospitals it is costing public funds £16 a week to maintain these people? Is not that a reasonable argument?

When this Bill was announced I took it for granted that there would be some guarantees in it for our old people, who constitute our biggest health problem, but there is nothing in this measure which makes it mandatory on these bureaucrats who are being set up under the Bill to ensure that such allowances will be paid. I am making the case that the functions of this Bill will be administered mainly by the Minister and the bureaucrats who will be appointed.

I am reading the funny pieces in this book entitled The Health Services and their Further Development—funny pieces in the light of what is happening at present. The Minister states that the officers of the board will be responsible for the financing of all projects, that they will hold the purse and that, by virtue of holding the purse, they will be able to direct the executive officer as to how he will work. What is happening in Dublin Corporation? They are holding the purse, too. What happened when they did not act according to the dictates of the Minister? What happened when they said: “We will not give you this £800,000 extra which Dublin Health Authority require. On a former Minister's assurance that was to come from the Central Fund?” What good did their holding the purse strings do then? We shall soon know because if the election is held in the not-too-distant future nothing will happen, but if the election does not come for a long time they may be dissolved. The Minister is smiling. If the Minister and the Government persist in the dictatorial attitude they have adopted about such matters, Dublin Corporation could cease to exist tonight; but possibly with the election pending some other way out will be found.

It would be a matter for another Minister.

I referred before to the collective responsibility of the Government. "All for one and one for all" is the motto of Fianna Fáil. It is a secret how many boards there will be or what areas will be covered. The only reference in the Minister's statement in introducing the Bill is to the effect that we may have eight boards. We do not know whether that is so or not. We do not know whether Cork city and county will be deemed to be of sufficient size to warrant one board. But my mind moves back now to one of our senior representatives, Deputy MacEntee, when he introduced here in 1960 this unified Health Services Bill which established boards in Cork, Waterford, Limerick and Dublin. We were told then by the Minister that this was their final word on the administration of the health services and the provision of additional services, and that once this Bill became law and that once the health authorities to be established under it got under way everything in regard to health would be settled. Only nine years afterwards another Minister says: "No. Things have not worked out as we thought. We have to change this." We have special sections here wiping out the Cork Health Authority, wiping out the other authorities, and, as I have said five times over in these remarks, giving the Minister and his appointees power to take them over.

Seeing that the Department is paying more than 50 per cent of the cost, I should be quite satisfied if the Minister had a representative or two representatives on a health authority, but surely there is no justification for a Minister saying that because the public funds, through taxation, are bearing more than 50 per cent of the cost he has the right to 50 per cent of the representation? Were it not that this is a move, as I mentioned earlier, to wipe out local democracy and local bodies, the same kind of case could be made for representation on county councils. I thought Fianna Fáil had changed so far as the appointment of non-elected members to boards is concerned. I remember when Deputy Smith as Minister for Agriculture introduced a measure here providing that more than 50 per cent of the members of committees of agriculture should be elected members of councils, but when the Government fell out with the NFA and other farmer groups, Deputy Blaney, the Minister for Agriculture and Fisheries, said in 12 months time: "We made a mistake. What are we going to do? In Deputy Smith's Bill we are giving these fellows who will not have to face the electorate an opportunity of being members of the committees of agriculture" and it was changed overnight. I thought at that time that the emphasis lay on public election, but it is quite evident that, so far as the administration of Fianna Fáil is concerned, expediency is the main motive behind every move.

I should like to ask a few questions. The choice of doctor is one of the items on the credit side of the Bill, an item that could be introduced without any Bill at all, by means of short amending legislation. I should like an explanation of this statement by the Minister at column 1637, volume 239, of the Official Report of 16th April, 1969:

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;

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

If a person, say, living in a village wants to register with a doctor in a town 15 miles away is he allowed to do so? The Bill does not say so. The Minister says he is likely to make regulations restricting such a person from availing of this service because, according to the Minister's opening statement, the main hindrance is as to distance. As regards the control of entry of doctors into the service, supposing four doctors are operating in a particular town at the present time, is there a likelihood that if all four opted to enter the service all four would not be accepted? If that likelihood exists, then to my mind there is not a choice of doctor; in fact, according to this measure, a person could be assigned a particular doctor. I should like the Minister to define what he means by this paragraph I have just quoted.

As regards the charges for services, under section 15 of the present measure any middle income group person entering hospital for treatment knows that the maximum daily charge is 10/- per day. Under this Bill there is no charge spelled out. This is to be done by regulation. I do not think it is right of the Minister to take that power unto himself. He should state specifically whether or not he thinks the 10/- rate is obsolete, whether or not he will have a rigid means test, whether or not he will send assistance officers to families in the middle income group inquiring about the number of cows, hens, or anything else they may have. Is that the system he proposes under this measure? It is not a system that commends itself to me. Indeed, I believe the present system under which everyone knows what the inclusive maximum charge is per day is the better system.

I think the Minister has his eye on the voluntary hospitals. I believe he has it in mind to bring them to heel a little. The voluntary hospitals depend largely on public funds. Most of their patients are paid for out of public funds. These hospitals have played a very important role down through the years. Their services generally are well up to standard. Many of those staffed by religious have given outstanding service to the community. I should not like to see their freedom of action taken from them. I do not believe there is any general demand for that. If the Minister interferes in the management and administration of these voluntary hospitals the likelihood is that he will worsen the position instead of improving it.

So far as district hospitals are concerned, they are catering mainly for the aged chronically ill. I am not at all satisfied with the system under which they operate. Admissions and discharges are more or less the gift of the doctor or matron for the time being. Though the hospitals are maintained from public funds they are administered in a private sort of way and the result is that some people are admitted and others wait for years. Still others are never admitted at all. The system should be examined. Most of the cases in these district hospitals would be social cases. They are there because of lack of means. The only additional income available to them would be home assistance. I think it is very unfair—I have been hammering this home in the Cork Health Authority for years—that the only financial help available to people in the winter of their lives, after a lifetime of service and hard work, should be home assistance. I do not reflect on home assistance, but there is a stigma attached to it. Because of that stigma many refuse to accept it. Surely these people could be paid a disablement allowance? Whether the allowance comes from rates or taxation, or partly from both, is of no consequence; no one would object to such an allowance being given to these incapacitated people.

The treatment of mental ill-health is of paramount importance. Clinics staffed by competent psychiatrists should be provided. There should be domiciliary treatment, if possible; anything that will keep people out of institutions is to be commended. There was domiciliary treatment for tuberculosis patients and it was very successful. Some people object, of course, to attending clinics because they do not want the neighbours to know but, by and large, the numbers attending at clinics are increasing. Any mentally disturbed person should have treatment. Clinics should be established and patients should be encouraged to attend them. If some refuse to attend some other method of treating them should be devised.

So far as the larger mental hospitals are concerned there is urgent need for elimination of the big wards holding 70 or 80 patients. There is no justification for wards of that size. There should be wards holding not more than 10 or 11 patients. That will necessitate more staff and more supervision, but the provision of such staff should not be beyond our competence.

I am pleased to note that some improvements are being effected in that direction in Our Lady's Hospital in Cork. I have been a member of the committee there for more than 20 years and I know every nook and corner in the building. I am fighting all the time against large wards. If people were to see so many housed in such a congested fashion, it would be enough to create a disturbance in their minds. I am asking here, then, that particular attention be paid so far as our mental institutions are concerned to the partitioning of wards, to reducing their size. It is completely inappropriate to have wards holding 40, 50, 60 and more patients.

I have examined closely the advantages of small institutions with particular reference to the hospital known as Saint Ann's, Shanakiel, Cork. That hospital, with a complement of some 120 beds, was opened to the public some three or four years ago. It is one of the most modern psychiatric units in this or, indeed, in any country, I would say. It has a number of private wards for special cases. The general wards are usually small and the complement of patients in most of them is small. Everything is laid out in an exceptional manner. Undoubtedly, a patient receiving treatment in such an institution has a much greater chance of recovery than one would have in, say, the main old building or in the old mental institutions that still exist. I agree that chronic patients are not suitable to be housed in such mental hospitals. Smaller institutions such as Shanakiel, with sitting-rooms and restrooms which compare favourably with similar rooms in any modern hospitals, represent a great step forward and undoubtedly, taking Cork Health Authority hospitals into comparison— Our Lady's and St. Ann's—the difference is vast. It ranges from the low end of the scale, so far as some of the old buildings in the main part of the hospital are concerned, to the lavish surroundings of the recentlyerected modern unit there.

I am all in favour of providing small units where it is deemed necessary to establish mental homes in the future. However, with all the medical advice that is available to the Minister and with all the advances that are claimed in the field of mental illness, one would anticipate a reduction in the number of people requiring psychiatric treatment but, unfortunately, that does not seem to be the case. One would think, also, remembering another phrase of Deputy P.J. Burke about our affluent society, that if, as he states, we are much more affluent now than we were in the past, that should ease tension and possibly result in a reduction in the number of persons requiring institutional care for mental illness.

I am sorry for prolonging the debate but even though I said at the outset that there was nothing in the Bill I think it is right that Members should address themselves to all aspects of the health services. Even though some may deem it unnecessary to speak at length, each member of the House is entitled, in discussing this measure, to address himself to all aspects of the health services.

The problem of mentally handicapped children was an exceptionally heavy problem in Ireland in the not too distant past and to some extent is so today. I appreciate the problems confronting parents in County Cork who have mentally handicapped children and the great burden they have had to bear in caring and nursing such children and in endeavouring to provide some type of education for them. I appreciate the many fruitless calls they make on various people for help in getting institutional care for these unfortunate children. Such care was available only in a very limited way. But, in recent years, thanks to the Polio Association in County Cork, and to the very active committee in charge of it and, indeed, to the very active secretary of the committee, Mr. Bermingham, great strides have been made in the provision of accommodation for mentally handicapped children in Cork city and county. The advances made are far in excess of what would have been made if the problem were left to the Department of Health or, indeed, to local authorities to deal with. Great relief has been given to parents by their children being taken to homes in the city and cared for in an excellent way and trained, in so far as it is possible to train them. The work of that organisation for the care of mentally handicapped children cannot be over-emphasised. The association deserve any support or help that can be given to them from central or, indeed, local funds. I have particular regard for the very capable chairman of the association, Canon Bastible, as well as for the secretary, whom I have already mentioned. Canon Bastible was one of the main movers in this worthy enterprise for the provision of accommodation for the mentally handicapped.

I want information from the Minister as to why he has left home assistance with the local authorities. Is it only because local home assistance is a local charge and the Minister does not make any contribution? However, I am doubtful if this is a wise move because our allowances, or the allowances that would be payable, say, by a health board, are in many instances supplemented by a home assistance allowance. That being the case, I think that one body, irrespective of which body it is, should manage or control both allowances. It is quite evident, of course, that the health board is going to control the disablement allowances. Much as I dislike handing over powers to this type of board which it is proposed to set up, I do not see any great advantage in segregating the administration of both allowances, leaving one with the health board and another with the county councils.

Another service I should like to refer to—I do not wish to hold up the debate much longer—is the availability of blind welfare allowances. Before 1960, when we had separate health authorities in County Cork, all blind people who qualified for the maximum old age pension and who were so certified, automatically qualified for the maximum blind welfare allowance. At that time contributory pensions did not exist. Blind people in West Cork were financially much better off then than their counterparts are today.

When the Cork Health Authority came into existence they changed that system to a more niggardly one. Such applicants were in many instances refused any assistance and in others only small allowances of 10/- or 12/-a week were conceded. Those of our people who are suffering from this great affliction, possibly the worst, should not be dealt with in such a niggardly fashion. Those who were entitled to the blind pension should automatically qualify for the maximum blind welfare allowance without any means test whatsoever. The number involved is not great.

Another matter which will not be affected to any great extent by this measure is the disabled persons' allowance. The opportunity should have been taken here to adopt a more liberal approach to applicants for such allowances. I appreciate it would cost money but, as I have stated again and again, those of our people who are incapacitated are entitled to our consideration.

I have stated already that an exceptionally bad feature of this measure is the power it gives to the Minister and his boys in the public service. It wipes out the powers of the local representatives. It is dictatorial and totalitarian. I do not like that because it will play havoc with the functions of local representatives and with our health services. Henceforth we will be directed by the Department, by people who need not present themselves for election. The public representative is being demoted, downgraded like the county hospitals, as suggested in the hospitals survey book to which I have referred.

It is frightening to think of what may happen under this legislation to people who may have legitimate grievances. They will have no redress. I am damn sure that if any of them calls on the chief executive officer of the health board he will not be seen because these executive officers will not be available to talk to individual applicants even during working hours. Public representatives were glad and willing to see them even after hours.

I am fearful about some of the proposals in this hospital survey book. I do not see much danger of some of the outlandish suggestions in it being implemented but we must appreciate the power the Minister is being given under this Bill and the composition of the health boards. Therefore I call on those interested in retaining county hospitals throughout the country to make their voices heard if they want to keep those hospitals. In view of what is in the Bill, in view of the Minister's pronouncement on 14th December last about hospitals such as those at Bantry and Mallow and those mentioned by Deputy O'Hara, there is grave danger that those hospitals will be downgraded.

This measure casts aside the people and implies that it is only the bureaucrats who know what is good for them. The proposed new system bears a close resemblance to that which obtains in Eastern European countries where the State directs the citizens and where the citizens' views are not taken into account. This Bill seeks to implement a similar system here.

I said in my opening remarks that this is a measure which would qualify for introduction in many East European countries which I have visited and where the citizen is cut out. Therefore I wish to repeat and to emphasise the statement I made at the outset that this is a move to wipe out local representatives. It is a dishonest move in that direction and if it succeeds it is reasonable to assume that in the not too distant future the system of local representation which has served our country and our people so well will be abolished altogether.

They are the only comments I have to make on this measure. Of course, everybody agrees there should be choice of doctor. It did not take a Bill of 40 pages to tell us that—this kind of wanton waste of words and phrases, superfluous in every respect. When, in the name of heaven, will we bring Bills into Parliament in simplified language? A person who wishes to obtain this Bill must send three shillings to the Government Publications Sale Office in order to find out what he is entitled to. Where will he find it in the Bill? We are following the old British system in the way in which we present and draw up measures here. In some cases this has helped some of our brethren in the legal profession because, in order to clarify questions that have arisen on sections or subsections of Acts, we have had to go to these learned gentlemen and sometimes through them to the courts.

I do not propose to support this Bill and I have given a number of reasons why it should not be supported. I am in agreement with the abolition of the dispensary system, which we have had for too long. It led to too much discrimination and many who had to avail of the system were not getting the service they should have got. So far as other matters in the Bill are concerned they could easily have been brought in by way of regulation. We were led to believe that an allembracing Health Bill would be introduced. I need not detain the House dealing with the Cork Regional Hospital for which no sod has yet been turned and will not be turned for some time. I have made my views on that position clear a number of times. Possibly this Bill has been brought in as an election measure. People were anticipating health legislation and the Minister expects that all that they will take cognisance of is that there is new health legislation and it is supposed to be of marked advantage to them and that may help Fianna Fáil over the election hurdle which confronts them.

It would be quite easy to describe this Bill in the words used for the title of one of Shakespeare's plays: "Much Ado About Nothing" but the trouble is that it would not be an apt description. The main feature of the Bill is that it is taking from the local representatives power and giving it to the Minister and to the bureaucrats in the administration of the health services. That is a big feature in this Bill and I hope there will be protests about it. I hope that everybody who is anxious to keep open hospitals in local centres will protest. I did not refer very much to Bantry Hospital because I expected that it would not be downgraded and that no hospital board or authority would allow that to happen, but under this Bill it can happen as it can happen in Mallow and in the other nine or ten centres mentioned in this Bill. It is about time that local people, particularly those not having the Fianna Fáil label, told Fianna Fáil what they think of this Bill so far as it relates to administration. I hope that at the next election the people will bear these facts in mind, whether the election comes in May, June, October or April, and that as a result of all the accumulated effects of such blunders the Minister will not be on that side of the House to propose any further legislation. However, I hope at least the Minister will be here, if he is fortunate enough to escape the electorate.

I am very disappointed with this Bill, so are the people and particularly the people of the Minister's native county, Mayo. I had hoped that the Minister would have brought in a Bill which would have improved our health services, but if we are to accept this measure I am convinced that we will be going into reverse gear. I am saying that having been elected to Mayo County Council for the past six years and having had experience of the methods by which hospitals are administered not alone in my own county but in other counties. I agree with Deputy Murphy that it is a retrograde step to take away powers from elected representatives. The people will regret this step which is being taken by the Minister. I agree that the Minister is trying to take dictatorial powers.

None of us was elected to our local councils without having to go before the people to get their vote and the fact that we have been elected for one term after another is proof that the people were satisfied that we discharged our duties honestly and faithfully. It should be remembered that the members of the various county councils are, in the majority, members of different political Parties, and of course we also have independent councillors. In the main these people are of some standing in the community. They have had the confidence of the people and if they had not got that confidence they would not have been elected. This is a grave reflection on councillors throughout the country, many of whom have served voluntarily for years without a penny reward, and not only that, but in many instances with serious losses to themselves, having to spend their time away from their businesses, their farms or professions. I have known and worked with these people of different political persuasions. I have seen them spend from 11 o'clock in the morning in many cases until 11 p.m. or perhaps until 2 a.m. the following morning at council meetings debating problems that arose in the various institutions within their responsibility.

In the old days the problems were much more serious than now. We had the tuberculosis problem. I remember when first elected to Mayo County Council that we had about 300 or more patients on the waiting list and we had no suitable accommodation for them where they could be treated medically and nursed. We had to tackle that problem and also the problems of mental health and extensions to institutions. We had to discuss with our medical and nursing staffs the various day-to-day problems that arose. Nobody will deny that the system operating for some years past has, in the main, given satisfaction. Certainly, I shall not be convinced by the Minister or anybody else that a board which is appointed as to 50 per cent by the Minister and has certain other appointees, probably people with little or no experience of the running of institutions, will give confidence to the people that the Minister is travelling on the right road.

I am aware that when people become ill they like to go to their local doctor. They may also like to consult a local councillor and if he is not of their political persuasion they can always travel or send a note to a councillor some distance away who is, perhaps, a member of another political Party, and ask his advice. When one considers the experience these councillors have gained through the years, one realises that help and advice is appreciated by the patients. We should remember that applies particularly in rural areas. The Minister, like myself, comes from a rural area and must know the feelings of those he represents since he was reared among them. I think that the people who elected the Minister to the Dáil will be very disappointed if this measure becomes law when they realise the type of measure it is. They will not be convinced that this is the type of legislation that is likely to give a better health service.

Deputy Murphy has long experience also of the running of hospitals in Cork city and elsewhere and gave us the benefit of that experience. I emphasise that I agree entirely with the points made, and when I say I agree with him let it be understood that we are both speaking from practical experience. This proposal is an insult to the elected representatives who have served voluntarily and furthered the cause of the sick and the needy through the years. The fact that they are now being scrapped and that boards will be set up of persons, many of whom will not be known to the people at all, will shake confidence in the whole health system. I have no doubt of that.

Deputy Carter, a great friend of mine on the opposite side, this evening interrupted Deputy Murphy to remind him that this is a great measure, or words to that effect. Not so long ago Deputy Carter was very critical of a former Minister's proposal to close down Longford District Hospital and transfer the patients to Mullingar. He made a very important point that these people come from different towns and townlands such as Drumlish and Newtownforbes and many other towns and villages west and north of Longford town. He said it would be completely against the grain for these people to be taken by ambulance to Mullingar 25 or 27 miles away. He said he was opposing the move and would continue to oppose it bitterly. He pointed out, as I have done, that those he represented would be entirely against the change, that it would create many problems for his neighbours and that he would do everything in his power to prevent it happening.

I was surprised this evening—I have great respect for the Deputy—to hear him say by way of interjection that this was a good measure for our people and that for all practical purposes he could recommend it to the House. Roughly, that was the sum total of his interjection. I could not understand this about-turn or see that things have changed so much within two years. He must have been indoctrinated by his Party since he expressed himself here in other terms on previous occasions in my hearing. We know that part of the cure of patients is to have them happy about their doctors and nurses. Above all, when they must avail of institutional treatment they should be happy about the surgeon, the physician, the nurses and everybody else. Generally speaking, they like to be within a reasonable distance of their homes where neighbours can visit them when they go to town for shopping purposes. That is a great help and a great benefit to sick people. I myself had five years in hospital on one occasion and I know how much it meant to me when some friends came in to pay me a visit for a few minutes. It helped to pass the day.

If we adopt the principle that is embodied in this Bill of providing big regional hospitals for groups of counties, while we may in certain cases effect economies, the whole thing may defeat its own purpose. Far from having the effect that all of us would desire and, certainly, that the patients who enter these institutions would desire—the hope of being cured—it will have the opposite effect.

I believe that it will cause panic in the country and the people will be totally dissatisfied with it when it is fully explained to them, as it will when the election comes, if not before. It is a great insult to the elected representatives of the different political Parties and to independent members of county councils who, down through the years and without any reward, have given of their services and talents—big businessmen, solicitors, teachers, small farmers and others who pooled their knowledge and worked in co-operation with their county managers. It is an insult to members of health staffs, doctors and nurses who, as the Minister knows, in County Mayo, succeeded in improving the services and in clearing the long waiting list of TB patients.

It is true that it has been costly, but one cannot count the cost when it is a matter of trying to provide the best health services. Speaking of money, I must say that I am convinced that much saving could be effected in many hospitals throughout the country if we introduced better business methods into hospital administration. Economies could be effected in every institution under public health authorities without regionalising our hospitals if only we got down to the fundamentals. I am convinced there is much waste and a certain amount of overlapping and that a lot more could be done to effect economies if the Minister took the necessary steps to see to it that some of the methods employed in the running of our institutions were changed.

I have it on reliable authority that a considerable amount of drugs which were being used up to two, three, four or five years ago and which were considered to be outdated or, at least, not up to modern standards or requirements, were dumped. It happened in a number of cases. Therefore, I believe that the method of requisitioning drugs is very loose and needs to be tightened up. I am not speaking of any institution within my own county but I am speaking in a general way when I say that, in my opinion, the method of storing drugs in many of our institutions should be improved. It is a matter that should be checked on with great speed by the Minister or by his officials.

I am satisfied, too, that economies could be effected in many other ways. We have a system to which I have referred here before and which I have mentioned many times in Mayo County Council. It is the system whereby certain doctors and surgeons have the right to private beds for their patients in certain institutions as part of their remuneration. I condemn that system, as I condemned it before in my local county council. That system lends itself to abuse. It lends itself to a situation in which the rich can get early admission to these hospitals because they are in a position to pay. Let it be understood clearly that the nurses who work in these private sections where these patients are accommodated get no private fees for the extra attention they must give to these people who, as I say, belong to the wealthy classes. That creates an atmosphere in which it appears that, if one wants to get the best that is going, there is one way of getting it and that is by paying for it.

That fact is generally accepted by the rank and file of our people when they are going into institutions. They believe that, if they hold a medical card, they will be regarded as third-rate citizens and that they will get only third-rate treatment. But I must say, in fairness to the doctors I know in my own locality and throughout the country, that it would not be true to say that they give these patients anything that could be regarded as third-rate treatment. They do as much for them, in so far as I know, as they do for the wealthiest in the land. For that, I gladly give them full marks and full credit.

I do not wish it to go abroad that I am alleging that any private general practitioner in my area would refuse treatment to any person if that person did not have any money, but the fact remains that, because these doctors claim the right to have their own patients in these institutions, an atmosphere is created in which a lot of people believe that to get proper service one must be able to pay for it.

I have fought for the abolition of this system for many years and the statements I made were misrepresented by the newspapers, particularly the local newspapers. My statements were twisted and changed and at one stage there were a number of doctors who were not even on speaking terms with me. But, as time went on, they discovered that what I had said was not intended in any way to be personal and that I had not referred in any way to their personal integrity, so that for many years now I have been able to live and work with these men. It would be far better, in my opinion, if, instead of giving them 11 or 12 beds in the county hospital in Castlebar or Galway or in any other county, those surgeons and doctors were properly remunerated. If they want £4,000, £5,000 or £6,000 a year, or whatever they are entitled to, we should be generous with them.

Proper control should be exercised over beds, medicines, tablets and all the rest of it. It is quite natural, if everybody is drawing from the medicine chest tablets, bandages and bottles of this and that, we would be in the poorhouse in this city or in any other town in Ireland. If things were run in that way we would not last long. Auditors come around to carry out inspections and they would be concerned about this. We have them in Mayo and I am sure they have them in other counties. I refer to these things because I feel there is need for tightening up, but there is not anything in this Bill which will help in that respect.

Another thing we should remember is the striking of the rates. My own county is the highest rated county in Ireland and it is also one of the poorest, although perhaps not in the Minister's part of it. Some of the parts I represent are very poor. I refer particularly to Erris and Achill as well as some other more congested areas. In those areas are poor people who find it hard to meet the rates demand. In the present year they were broke trying to find money to meet the rates. Now they find that health services will run to as high as 46/- or 47/- and there is nothing in this Bill which will have the effect of reducing by even a farthing the rates in Mayo.

In Dublin they have reached the stage where they have refused to strike the rate. I am not going to say anything about that but it should be borne in mind, and the Minister should know this well, that the people of Mayo have really made up their minds that they have reached the limit. In fact, we have gone beyond the limit; but we had the courage to strike the rate because it was felt that, if we did not do so in relation to health, we would probably deprive many of our people of the services which we feel they are entitled to. If we have to economise, quite frankly I would not like to think we would start to economise on health. It is the very last item that I should like to economise on. We have to bear in mind, first of all, the responsibility we have to our people and, secondly, the fact that the Minister's Department give us a very substantial contribution roughly in accordance with the rate we strike locally.

As I said, there is nothing in this Bill which would encourage our people to look forward with the passage of time to a reduction in health charges. We are now reaching a situation, if this Bill becomes law, in which we must pay our share of taxation but can no longer ask any questions about how the money is being spent. Our elected representatives, no matter from what side of the House they come, will no longer be able to answer questions about how the money is being spent. We will have to turn to people who will know very little about the matter. They do not have to face the people at election time like the other people on county councils have to. I am sure when those councillors face the people at election time they will tell them the truth—that they got a demand from the board and were told: "Like it or lump it, that is the demand". At the same time they have to ask the people for support to elect them to a council which has lost, so far as this matter of health is concerned, all power and all authority. We will have to tell them in future that there is to be a board composed of a number of elected representatives, some medical men and some having a mixture of this, that and the other. Those will be known as regional boards. We do not know anything about them. That is a most unsatisfactory situation, in my opinion, and it is the direction in which the present Minister for Health is travelling at the present time.

Reference has been made to the smaller hospitals. We have a number of them in Mayo. One of them at Swinford was the old fever hospital. Thank God, we have got rid of some of those fevers due to the advances in medicine and supervision in regard to water and sewerage. Because of this the health of our people has improved generally. We have not now got the old fever hospital at Swinford. We have in its place a new 40 to 45 bed modern hospital, which is run by nuns. I think the matron is a nun but there are also lay nurses there. As the Minister knows, they derive the greatest satisfaction from their work. They know all the patients. Many of my neighbours and, I know, many of the Minister's neighbours go down to that hospital. They spend a week or two there and after treatment they are able to return home. They know they are only 10 to 15 miles away from their own locality. On market days and fair days the neighbours drop in on them. They bring them some fruit or maybe a drink and this is of great benefit to the health of those patients. It gives them confidence that they are being well looked after and that they are among friends.

The matron, the nurses and the doctors know every patient by name, be it John, Pat, Mary or Margaret. They know the relatives and friends of every patient. In such an atmosphere the patients feel very happy. That little district hospital and also one which is run by another doctor, who will be nameless, is well-known to the Minister. This other hospital is near the boundary. The patients there all have the benefit of their neighbours visiting them.

This type of hospital is very good for the purpose of treating minor illnesses. But, according to a statement read out by Deputy M.P. Murphy, it is now proposed to economise by closing down that type of hospital or, in certain cases, having old people in them. There is need, unfortunately, at present for more accommodation for old people. Thousands of our neighbours have gone to England and taken up employment there. Hundreds of them have settled down and got married. For a while they were able to come back to look after the old people but, now that they have families of their own and jobs where they must watch the clock, they cannot do this. We know that the number of old people is increasing annually. It might surprise the Minister to hear that, even as a member of Mayo County Council, I failed to get a person into the County Home in Castlebar. I rang the matron and she told me that the place was packed. The people who asked me to make representation could not understand it and I could not myself. If any attempt is made to close down these institutions it will come as a shock to people all over the country.

Surely the Deputy misunderstands the situation?

I hope I do, but this has been stated by Deputy Murphy, and the Minister is on record somewhere as having said that a certain number of these hospitals would have to be got rid of. I do not know his exact words but he said that we would have to regionalise in the interests of economy. Perhaps it is a matter of pounds, shillings and pence without any consideration for the health of our people.

Did the Deputy read the report?

I read the Minister's speech.

The Deputy did not read the report?

I am not sure that I did.

I am sorry for interrupting the Deputy.

From what Deputy Murphy said and from my own knowledge I know that there is to be an attempt to regionalise. I fear that it may be in the Minister's mind to close down some of those institutions. I should like to have an assurance from the Minister that that will not happen in places likes Swinford, Ballina— which is being extended—and Belmullet. Speaking of Belmullet, it is a strange thing that, although we are short of beds in Mayo, Belmullet Hospital is being used as a county council office and, I think, the district court sits there. That is an extraordinary state of affairs when there is urgent need for that hospital to be in good working order and properly staffed to serve the Erris region. In future I suppose I will not represent that area but, nevertheless, I have a duty to mention it here.

Deputy Dr. O'Connell said that implementation of the Bill will depend on agreement with doctors and chemists. It will depend on the goodwill of doctors and, I suppose, of chemists to a lesser degree. At least one or two Ministers for Health have tried to create the type of atmosphere necessary to ensure that any Bill such as this would benefit the people we aim to help. It is true that the present Minister is leaning over backwards in an effort to create a better climate than existed heretofore between the Minister for Health and the doctors. I feel obliged to say, in passing, that we owe a lot to our medical men and nursing staffs, religious and lay, nurses in voluntary hospitals particularly. I value, and I am sure the general public and Members of this House value, the wonderful service they have given down the years, in times when money was scarcer and beds were scarcer and they had to make do in many ways. An old nun in Swinford who is still, thank God, with us and must be nearly 100 years of age, told me that the only method she had of heating water in the old hospital in Swinford was a tar barrel on a turf fire in the backyard. They did wonderful things in spite of those difficulties.

I do not think there is anything in this Bill which will take our dental service out of the doldrums. In Mayo however we have built on good, solid foundations. Some years ago a county dental officer was appointed. He left and another man was appointed in his place. We are under-staffed to the extent of two or three dentists. I am aware that in other parts of the country dental services are not all they should be. I am convinvced that the salary or conditions or something must be wrong when we are exporting our dentists to London, to the United States and to the four corners of the earth. The Minister should communicate with some of those people and ask them what has brought them so far from home. They are prepared to help in other countries, and we do not grudge that, but our own people should come first. Dental health is of the greatest importance.

Debate adjourned.
The Dáil adjourned at 10.30 p.m. until 3 p.m. on Wednesday, 23rd April, 1969.