Health Bill, 1969: Second Stage (Resumed).

Debate resumed on the following motion:
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.)

When speaking last night, I expressed, as some of my colleagues had done, dissatisfaction at the small improvement being given in this measure. After the 1953 Act had been applied throughout the country, there was, and still is, great dissatisfaction with the different features of that measure. I do not think the Bill we are discussing provides any great improvement: I believe it will leave the people as confused as ever with regard to their entitlements under the heading of health services. The people still believe they are not being treated properly as far as health services are concerned.

This Bill requires means tests and we should go to the utmost to get rid of such tests, particularly where health is concerned. My Party advocate a free health scheme embracing the whole community. We know that the people who violently opposed this in the past are still violently opposing it now, but the main opponents still appear to be Fianna Fáil. They do not want to go the whole way in providing the service we in Labour have advocated, and though Fine Gael have proposed a health scheme embracing about 90 per cent of the community, they do not go the whole way with us.

I repeat that our proposal is a free health scheme for all, because we believe it could be administered more easily and effectively than that proposed by Fine Gael. There are those who oppose such a free-for-all health scheme on moral, ethical and financial grounds but I should like to remind them that they were the same opponents to Labour's proposals for free primary and secondary education as far back as 1929. Therefore, there should not be any moral or ethical objections to a free health scheme for all our people.

In our social welfare and health services the State always seems to want means tests. We have a number of examples of this in the application of such social welfare benefits as pensions, whether they be for old age, widows or orphans, blind or others. Perhaps we are not any more peculiar in this country than in others in that we appear to have means tests in the matter of providing grants for assistance to the poorer sections of the community, but when we come to other things there does not appear to be any means test. For instance, if a person wants to build a house, to certain specifications, of course, he gets a grant from the local authority and from the State without any requirements as to income. Industry is another example. Whether people need grants or not they get assistance from the State. We also have free-for-all provisions as far as children's allowances are concerned: they are provided irrespective of means.

I suggest, therefore, that as far as health is concerned we should have a free scheme, that we should not subject people to hardship because they appear to be on the income borderline —because their income may be a few bob a week more than the required amount for entitlement to medical cards. We have a free health scheme in one small respect, to cover what are regarded as infectious diseases: the treatment of these is absolutely free to the community. Therefore, we should aim at a free health scheme for all our people.

I should like to repeat what Deputy Kyne said in this respect. I do not think it would be possible to introduce a free health scheme immediately this Bill becomes law. It would have to be done in stages, having regard particularly to the financial aspect. This is what we should aim at but from what I understand of Fine Gael's proposals, we wish to go further.

We have gone a long way.

Labour's proposals are a little advanced in that we want a free health scheme for all our people. A lot of people may be deterred by the example in Britain where the British Labour Party would be the first to agree that mistakes have been made and that there must be amendments: their scheme went awry in respect of many features. As I have said, we should not be deterred by that. The ultimate objective should be a scheme which will provide for all our people and which will not leave families in a position where they get into serious debt because they do not qualify for medical cards and because, at the same time, they cannot be in a voluntary insurance scheme. The people I refer to are in the middle-income group. Many of them have been left in a very bad way because of hospital and general medical expenses.

I wish to say here a word of praise for the majority of our local authorities who show concern, one might say compassion, for those who have not got medical cards but who have had to incur heavy medical expenses. In many cases in which drugs are required they have remitted the full amount of the charges. That would be in cases where people show hardship in the provision of drugs in cases of protracted illness.

The great deterrent in a free health scheme is the fear of the finances that would be required. One of the biggest disappointments in the measure now before us is that it does not provide for any substantial change in the financing of the scheme throughout the country. The present system of financing health services, and the system proposed in this Bill, are grossly unfair to those who have to meet the greatest part of the burden—the ratepayers. The present health services are financed by contributions from the rates struck by the various local authorities, plus a contribution from the Exchequer. The system which the Labour Party propose is one through which a far greater number of the population would participate in its financing.

In the present situation, the householder is responsible for the payment of rates. The father may have £20 or £25 a week. Three or four sons may also have similar amounts but the tax bill is presented to the father, to the householder. He must pay the rates in full. We have no hesitation in saying, as we proposed in our health policy document, that the burden should be shared in order to embrace these people. We believe that the burden of local taxation as far as health services are concerned, and, indeed, as far as all rate charges are concerned, is unfairly placed on the head of the household and we believe it should be spread because, after all, those who do not contribute directly to the rates, those who do not directly contribute to local charges for health services can avail of them. This is particularly pinpointed in the new suggestion in this Bill where by in the majority of cases a person's income is regarded as being his own for the purpose of qualification or otherwise for a medical service card.

Our idea would be that the rates should make a contribution, that the Exchequer certainly should make a contribution but that every working citizen or any citizen who has an income in the State should also be required to contribute weekly to a social fund. We believe that this social fund should be established, not alone for expenditure in connection with health but also in connection with social welfare benefits. As a matter of fact, we go so far as to say that there should be one Minister for Health and Social Welfare because there is a great alliance between these two. Those who are sick are dependent on the Department of Social Welfare for what benefits they may get by way of sickness benefit or on the local authority by way of infectious diseases maintenance allowance. Therefore, the Minister should examine the possibility of spreading the cost on to very many more shoulders than at the present time. I feel that if this system had been introduced five or six years ago we would not have the great furore we have now about the high level of the rates throughout the whole country.

The present services are limited and if we are to be honest with ourselves we must confess that they are limited because we have not got the financial resources. The Minister, the Taoiseach and some of their colleagues met a deputation of members of the Dublin Corporation and as far as I can gather the attitude of the Taoiseach and the Government was: "We just have not got the money" and I suppose their attitude also was: "If we give it to Dublin we will have to contribute to the other local authorities as well". But the Minister for Health and various Ministers for Health have hamstrung themselves in that they are confined to what the ratepayers can pay and what the Exchequer can afford from year to year. If other people benefit from the health services I believe they should share some of the responsibility for the financing of these services. I would include not alone health in that but the local benefits that are provided by the local authorities. They are benefits that are freely used by those who do not pay directly and it is a tragedy that for too long we have employed a system under which the householder is directly responsible for payment to the local authority for services like health, the roads that are provided, the light that is provided, the water that comes out of the tap and sewerage. All these things are of benefit to every citizen and we believe that every citizen who has an income, wages or a salary, should make a contribution towards these and particularly towards health which is so directly the concern of the Minister for Health because they also get the benefit of that service.

I know it would be impossible for the Minister to make radical changes in the Bill but he should seriously consider the suggestion in the Labour Party policy documents as to the financing of a health scheme and, of course, consequently extending it to very many more people rather than confining it, as it is in the main, that is as far as free services are concerned, to about 30 or 31 per cent of the population. If he is going to hamstring himself to depending on rates and contributions from the Exchequer we can only have the type of health service we have had up to this and the slightly improved one the Minister now proposes.

We have advanced in thought and in attitude in recent years because many of the things advocated by those who were regarded as radical ten or 15 years ago are now being accepted by all Parties in the House. Radical suggestions, if you like, from the Labour Party with regard to free education and free choice of doctor which were laughed at and derided so many years ago are now regarded as common place. Thank God the community and Governments are accepting that because these are desirable it is also possible for them to be implemented.

I should like to hear more from the Minister with regard to the free choice of doctor. He did qualify, in his statement or in the White Paper, the idea of the free choice of doctor when he mentioned that it would not be possible in some areas. This is very understandable. In towns and urban areas one can have a free choice of doctor. Perhaps, there will be three doctors in one town and seven or eight in another but there will be a choice. However, as far as rural areas are concerned what inducements there will be to have a doctor at all I do not know but I am sure there will have to be some incentive for a doctor to practise in a rural area.

In that respect I should like to subscribe to a view I heard last night, one which was probably mentioned by other members of the House, and that is the present position with regard to dispensary doctors and the uncertainty in the minds of people and particularly those who are members of local authorities as to the servicing with doctors of dispensaries where there is no permanent one. There is absolute chaos in the rural areas because a doctor who is not going to get a permanent appointment and sees himself there for years in a temporary capacity will not attend in the rural areas very often and will not act as a locum tenens because he believes he will be far better employed in a big town or city. The Minister will have to, even now before this Bill is implemented, and I assume it will take quite a time for it to be implemented, make some provision whereby dispensary doctors may be induced to stay in dispensary districts. In some places there is one doctor trying to serve three dispensaries. In dozens and dozens of cases there is one doctor trying to serve the vast area of two dispensary districts. There is utter dissatisfaction and there is neglect. It is not the doctor's fault but there is neglect of those who are sick and need to see a doctor urgently and in a case where there is a locum tenens if there is a call at night the doctor must travel, if he will, long distances in order to visit the patient in a dispensary district that has no permanent doctor.

I do not see much in this Bill to improve certain of the present services. One of the great deficiencies in our health scheme in the last 16 years, and there does not seem to be any improvement in this Bill, is the absence of a proper dental service. I do not know what the real reason is. It has been suggested that this country cannot get dentists because we will not pay them. Whether this is a fact or not I do not know. If this is the case we should be prepared to pay them because good care of teeth is vital for the health of a child. Because we have not got a proper dental service our children are suffering, and they are suffering from ailments caused by bad teeth which will affect them for the rest of their lives.

The scheme for the provision of dentures is an absolute joke. In many parts of the country, and in many local authorities, there does not appear to be any proper scheme for the provision of dentures. It is a terrible trick to play on someone who has a few teeth to tell him that he can have them out free and afterwards, when they are out, to tell him he cannot get dentures. Many of these are elderly people who, I would say, might prefer to have the three or four black stumps they had before rather than to have no teeth at all.

I do not think there should be any insuperable difficulty in providing proper professional men to give this service. I would not go so far as to say that the local authorities are falling down on the job. I would say that some of them are a bit dilatory in ensuring that this service is available to the people in their jurisdiction. The Minister should, as a matter of urgency, and even within the terms of the Act we are now operating, try to ensure that proper dental services are provided in every county or local authority area. If it is a question of money, we should provide it.

Incidentally, with regard to a question tabled by Deputy Treacy today, there was a suggestion that dentists should have a proper knowledge, or a speaking knowledge, of the Irish language. I am as keen as anyone else on the Irish language. I have always spoken in this House for the promotion or revival of the language, but it is a bit of a joke to ask people who have been in Britain for ten or 15 years to come over here to practice as dentists and then tell them, even tacitly, that if they have not got a knowledge of the Irish language they need not apply. I do not think it should be mentioned at all. We who want to come into this House are not required to have an Irish qualification. I do not know whether we are doing a better job than dentists. This should not be a deterrent to an Irish emigrant dentist who is prepared to come over here and work professionally for people in Ireland.

I do not know what the Minister can do in any substantial way for nurses. I suppose there cannot be provision for them in this Bill. We have all spoken on occasion about the hard and unhappy lot of nurses, their meagre pay and long hours. The Minister should concern himself about them. I think the late Deputy O'Malley did. Perhaps the Minister is doing so. I do not know. In 1969, in the second part of the 20th Century, we should not tolerate a position in which nurses have to work 12 hours a day and then go on night duty for a further 12 hours, and for ridiculous pay.

We all do.

I do not say it is entirely the Minister's fault. Whether it is the fault of the local authority hospitals or the voluntary hospitals is anyone's guess. My advice to the nurses organisations would be that they should become a registered trade union. If I am right, they are not a registered trade union, but they may have a negotiating licence. I do not think they have been militant enough. Let no one think that I am advocating that they should walk along O'Connell Street—although they might do so— or parade to O'Connell Bridge and sit down there. They have the example of the various trade unions in the country who in recent times, because of their strength and having regard to their talents, have got themselves reasonable salaries, wages and conditions. I do not think we should, by our silence, appear to condone a system under which a nurse is required to work a 12-hour day, and then go on night duty for another 12 hours for miserable pay and, in some cases—I will not say the majority—their accommodation leaves much to be desired.

And no overtime.

And no overtime, as Deputy Kyne reminds me. Next to the patients the nurses are the most important people in the hospitals. If we are to have good hospitals and proper treatment and care for the patients, particularly those who are in hospital for a long time, we should also look after the nurses who care for the patients.

Hear, hear.

I do not know if the Minister is in a position to go into any great detail about the regional hospitals. There is a suggestion that the regional specialist hospitals will be located in Cork, Galway and Dublin, and that there will be lesser hospitals in other parts of the country, which will be recognised on a regional basis. I think the Minister should have another look at this. He should reconsider what is now described as the Fitzgerald Report.

I know the Minister is a man who is not afraid of trouble but he will meet quite an amount of trouble not so much on the location of these hospitals, but on the downgrading of other hospitals. I do not know much about those who were appointed to sit on that commission and bring in that Report. I had occasion to say in the House that they had excellent professional qualifications. Were these men, reputable though they may be, the right people to say exclusively what type of hospitalisation we should have in this country? I agree that we should have these specialist hospitals. I do not think any of our county hospitals or district hospitals are equipped to do heart or brain operations or specialist operations.

I am concerned with the proposed down-grading of certain hospitals. I am alarmed at the fact that we are taking from the people a service which they enjoyed back to the Poor Law Board of Guardian days. I have several examples of my own and I am sure other Deputies have examples in respect of their own constituencies. So far as I can gather from the report, it is proposed, although not in a specific manner, to downgrade the Wexford County Hospital and, for that hospital, you can read any other hospital you like, the Clonmel County Hospital, or the Wicklow County Hospital, or the hospitals in any other part of the country you care to take.

I question the ability of those people to determine where our regional hospitals and county hospitals should be located. I believe this commission was weighted in favour of the specialists. There should have been other people on the commission, people who have been interested in and concerned with the administration of the health services for years and years, and the people who are on local authorities. I do not believe that all aspects were considered, or that the repercussions of the change were adequately considered by the eminent men appointed to that commission.

Is it suggested in the case of the Wexford County Hospital, which is located in Wexford town, that for treatment for an appendix a person should have to travel 40 miles to Waterford? Is it suggested that anyone who needs surgical attention will have to travel 40 or 50 miles, or in some cases in my area, 60 miles to get attention? Recently there was an accident in Wexford town in which a man suffered severe abdominal injuries. The county surgeon verified the fact that if he had not been so close to a county hospital, a matter of a couple of miles, and if he had had to go to Waterford with the type of injuries he had, he would have been dead before he was half way there. I do not think that hospital should be downgraded. The existing county hospitals should be upgraded, and given even greater facilities than they have at present.

This is a lobsided report and it should have included the experience and vision and wisdom of people who have served on local authorities, and of county surgeons and their staffs in the various county hospitals. I know the Minister set up the commission in good faith, and that its members were appointed in good faith, but I would ask him to think again before implementing the report, to have another look at it and consult with other people. I know he has many people in the Department with whom he can consult, but I suggest he would consult with the local authorities as well.

There are many aspects of this downgrading of county hospitals that ought to be considered. There is the medical aspect, and I have given the example that the distance is much too far for people to travel, particularly those who become ill suddenly and whose illness necessitates an immediate operation, or those who have accidents. It is just not good enough to suggest that they would travel 40 or 50 miles in order to have an operation.

There was a very representative meeting in Wexford town some two months ago, and it provided a very good argument for those who are in favour of the retention of the facilities that are in the County Hospital in Wexford. It was a week of snow and the roads were like glass. If a situation arose in Wexford town or in Wexford county necessitating the removal of a patient to Waterford city, it would have been impossible, because cars could not move. Therefore, we should not take away from the people this service they have had so long.

There is also what I might call the social side. People find great difficulty in getting to hospitals far distant in order to visit their relatives. County councils are not very flathúlach when it comes to issuing travel vouchers. Those in the medical card group find it virtually impossible to get free travel vouchers from the local authorities to visit relatives or friends in a hospital 10, 20 or 30 miles away. The regional hospital should not be located so far away that people would find it extremely difficult to make these visits.

There is another reason—I suppose it would not be regarded as the best one—that of economics. The hospital and its staff are part of the town. The staff are in receipt of wages and salaries and they spend money in the town. The contracts usually go out to the town in which the county hospital is located. If the hospital is removed to another area these benefits will be lost to that locality. That is not my main point in regard to the downgrading of the hospital, but regionalisation could do a disservice to the people in relation to the administration of the Health Act. May I appeal to the Minister to have a further look at that and not to depend on those who brought in the report, not to depend on those good officials in his Department, but to consult with the local authorities, to consult with the representative groups from those various areas in which there have been strong protests.

As far as the measure is concerned, we would recognise that there are some improvements. I cannot be too enthusiastic about them, but they are improvements and for that reason we believe we should support the Minister in his efforts. On the other hand, we want to express grave dissatisfaction that he has not introduced a real health scheme. He should be prepared now not alone to review it, because that has gone on since 1953 and particularly since 1961, but to say what the Government's policy and what his policy is. Do they believe there should be a free health scheme for which every citizen would be eligible? Does he believe that the burden of local taxation should be spread more widely in order to ensure that the ratepayers will not be hit so hard, and will there be improved and extended services?

We have waited for this Health Bill for a long time and I am quite disappointed at what has emerged. There are a few good things in it but there are many things that need explanation, and I am hoping that when the Minister is concluding he will enlarge on some of these matters.

In theory a free choice of doctor is a good thing and this is what everybody in the House wanted. However, I cannot see it working, particularly in my constituency. There are not enough doctors. I am not very clear from the Bill how it could work in an area where there was a dispensary doctor prior to this. Take a case where there is a dispensary doctor and a doctor in private practice. If there is a free choice of doctor and the medical card patient goes to the doctor in private practice, who pays the doctor in private practice? I do not know either how it would be decided that X area should have a medical officer, dispensary doctor, call him what you will. As the Minister knows, in the vast area of South Galway with a population of 8,000 people there are two dispensary doctors. In a wide rural area obviously two doctors cannot cope with such numbers. The new scheme will not improve it; in fact, it might be worse. All areas west of the Shannon, certainly Galway, the two Mayos, parts of Sligo and parts of Leitrim, will have to be treated like the Aran Islands: doctors will have to be appointed willy-nilly and kept there.

This country has gone in a peculiar direction in regard to health. We cater now for medical card holders, and this is a great thing. For too long were the people who could not afford to pay for services badly treated. I am delighted to see them getting treatment, but now it appears that the private patients have no rights at all. A constituent said to me quite recently: "I am paying gigantic rates and a doctor can refuse to see me because he is too busy." It is the ratepayers who are keeping the hospitals and the dispensaries there, and surely they must have some rights?

In Galway we have an astronomical rate: it is almost £5 in the £ in the county and it is over £5 in the £ in the city. Surely a person who is paying rates of this size is entitled to tip-top service, but this is not what is happening. We have a few doctors who are grossly overworked. Instead of encouraging people to stay in the west of Ireland, we are driving them out of it. We are not offering them adequate medical services; dental services are practically non-existent in the west; certainly they are non-existent in County Galway. Saving the west is something we hear a great deal about. If we give people proper services and amenities they will stay in the west. If a man is making a good living and suddenly becomes ill and dies because he could not get a doctor, what good is that living to him or to his wife and family? People cannot be expected to set up home in an area where they cannot even get a doctor.

Much has been said about this now famous Fitzgerald Report. There is a hospital in my constituency, the Portiuncula Hospital, which will come under the hammer if this report is adopted. It will become a health centre and will handle geriatric cases and, according to the explanation given to me, all straightforward maternity cases. There are only four Members in this House who can speak of maternity cases from personal experience. There is no such thing as a straightforward case. For over eight months of pregnancy a patient may be perfectly normal, but in the last three or four days an emergency may arise and even within the last three or four hours and the obstetrician, or whoever it happens to be, may decide that it is a case for Caesarean section and, in the middle of winter, the patient has to be taken 40 miles from Galway. This constitutes a desperate risk and, if I were the patient, I would refuse to go there.

Portiuncula is a new hospital, comparatively speaking; it is an excellent hospital and it is in process of expanding at the moment. It serves parts of Westmeath, parts of Galway, parts of North Tipperary and a little bit of Offaly. It fills in the gap in the Midlands. The hospital in Athlone is very small and there is no maternity unit there. I do not know if it has a surgeon. Actually, Portiuncula takes in patients from the Athlone area also. For those in County Galway and in the adjoining counties it will be a dreadful tragedy if Portiuncula is downgraded. As Deputy Corish says, there is more than just a surgical or a medical problem in the downgrading of hospitals. Taking a hospital out of a town is like closing down a big factory in that town because literally hundreds of employees are affected—doctors, nurses, cleaners, maintenance personnel, wardsmaids, porters, lift attendants, ambulance men and so on. Visitors visiting a hospital bring a great deal of business to the town in which it happens to be situated because visitors to hospitals invariably bring gifts to patients—flowers, grapes, cigarettes, sweets and fruit.

The closing of a hospital in these circumstances could well constitute a financial drain on the town and the loss of a great deal of money out of the town. There is, too, the difficulty of relatives and friends visiting patients in big regional hospitals. The distance to be travelled will be infinitely greater. As it happens, these hospitals are very sticky about visiting hours and, if one has to travel a long distance to the hospital, one runs the risk of being delayed because anything can happen on a long journey. If one reaches the door late then one just does not get in. With a local hospital one can get there in a matter of minutes. Again, it is imperative that parents should visit young children in hospital every day. If the hospital is a long distance from the children's homes then visiting will be impossible.

This Bill does nothing to help the ratepayer. Help was what we were all hoping for, but the hospital service will still depend on the rates. To put it mildly, the ratepayers are getting a little bit sore about the rising incidence of rates year in and year out. Now, because of the non-payment of rates up to a certain valuation, those who have to pay rates feel slightly aggrieved because they believe they are paying for a service from which they themselves derive no benefit. I know that the well-off section in any civilised community has a duty to care for the less well-off, but there are people who are aggrieved because, though they pay rates, they get no benefit from the hospital service and, as well as that, the service seems to get worse instead of better I do not see anything in this Bill designed to improve the hospital service. I do not think big regional hospitals are the answer. I am not, of course, an expert, but they have been tried in Britain and now, in Britain, they are going back to the idea of small local units.

With regard to the formation of these regional health boards, I think the Minister is getting too much power. I am not now speaking of the Minister at the moment; I am speaking about any Minister for Health. No Minister should have the power to elect the chairman and vice-chairman. One could easily arrive at a situation in which the Minister would look down a list and see that X paid so much to Party funds and here is a job for him and X might be absolutely and utterly incompetent in the particular job. That is one of the dangers. I do not say for a moment that the Minister would do anything like that, but Ministers are human and there is too much of an element of "jobs for the boys" in this. The powers of local health authorities are being eroded in this Bill and too much power is being vested in the Minister.

I understand that four CEOs will be appointed. One or two of these should be medical men. I know that various Ministers for Health have had uneasy relations with the medical profession over the years. I know the medical profession has been tricky and, perhaps, difficult, but then politicians are tricky and difficult too. Indeed, all professions are difficult. In fact, we are all difficult if someone rubs us up the wrong way. With the best will in the world these chief executive officers would not be competent or qualified to tell a doctor how to run his hospital. There should be at least one doctor, if not two, amongst these CEOs. He would see the pitfalls that the ordinary layman would never notice. I think this is a sensible suggestion, even though I make it myself.

I am glad to see provision for help for the old and chronically ill in their own homes. This service is urgently needed. I hope the Minister, when this provision comes to be implemented, will rely to some extent at least on the marvellous voluntary organisations which have done and are doing so much excellent work in this field.

In rural Ireland, in particular, we should really be ashamed of our treatment of the old and chronically ill. Some of it may be due to ignorance. Some of it may be due to carelessness. Some of it is due to the modern trend; children no longer want to look after aged parents or elderly relatives. In my constituency St. Brendan's is literally bursting at the seams and no more elderly people can be taken in there. Only last week a man came to me with a problem; he is living with his 94-year-old mother and, while she is quite mobile, he is afraid that she will fall into the fire, or something, some day. St. Brendan's cannot take her. It is in cases like these that the new provision in regard to care for the old and chronically ill in their own homes would be particularly advantageous. I hope this provision will come into operation as soon as possible. I do not know how it will be implemented, but I am sure it can be worked if time and energy and money are spent on it.

Deputy Corish referred to the living conditions of nurses. Time and time again I have been told by matrons in hospitals, even in training hospitals, that they cannot get nurses. Of course, they cannot get nurses. The living conditions are bad. The free time is bad. The pay is bad. Practically everything is bad. Local authority hospitals have pension schemes. Some of the voluntary hospitals have pension schemes, but not all of them. I know hospitals which have no pension scheme and the nurses stay on in these hospitals, working until they are 70 years of age and are eligible for old age pensions. That is a scandalous situation.

The regional hospital in Galway has a big nurses' unit with quite pleasant living conditions. The only drawback is that it is not big enough. As well as that, a new system, a disastrous system, in my opinion, is now being put into operation there. Meals used to be served in the diningroom and the cost of food was deducted from salary. Now they are starting a cafeteria system—pay-as-you-eat. Young nurses are human and, if it is a choice between a new skirt, a new coat or a holiday, and a proper lunch, the holiday, the coat or the skirt will be the winner. They will skimp on food and, skimping on food, their health will deteriorate. They will not be able to work if they are half-starved. This new system is a dangerous one and it should not be allowed.

There is some provision for dental services in this Bill. People do not seem to appreciate—this is particularly true of rural Ireland— the value of good teeth. Parents do not seem to appreciate the importance of making children care for their teeth. This sort of education could be given in all sorts of ways—through the schools, through lectures, through pictures and television. Television is a marvellous medium because everybody seems to watch it, certainly in rural Ireland. If the dentist were paid enough, they would stay. At the moment, the minute they are qualified they are gone. In some towns in my constituency there are none. In one particular town, the population has increased by over 1,000 but there is no permanent dentist there. A dentist comes there one day a week. It shows that the inhabitants of the town have no regard at all for their teeth. Even if they went to the dentist for a check-up once a year, a dentist would be kept more than busy. If teeth are neglected, it can lead to chronic ill-health.

This is a point that I do not think has been got over—particularly in classes—to the children, to parents, or to anybody. One sees even quite young children with their teeth broken or decaying and nothing being done. The tendency with them is to go to the clinic once and have all their teeth pulled out—one meets that with quite young girls and boys—instead of having simple fillings, and so on.

I want to mention the ridiculous position in our part of the world as regards the supply of dentures. I had a constituent once who told me that he had applied for dentures six years before that but had not got them. The next time I was in the county buildings I asked about the matter and, as a result, he got them. Some time after that, I met him but he was not wearing the dentures and I asked him why he was not wearing them. He said they did not fit him. It is easy to understand that a change in his gums would take place from the time the impression was taken for his dentures six years earlier. Surely the most sensible and economic thing would be to take out the wretched teeth and put in the dentures almost immediately? Because of changes in the gums, it is a complete waste of money to give a man dentures after six years which were made on the basis of the condition of his gums after the extraction of the teeth in the first instance.

We have a drug problem, even if we do not want to admit it, or, if we have not a drug problem, I am afraid we shall rapidly have one. I was glad to note that the Dublin Health Authority are to have a secret depot for storing their hard drugs. There was a time when, any evening one took up the Evening Herald, one seemed to read the heading “Another Dispensary Raided”. They are not raided for fun, obviously, if they are raided regularly. These drugs are used rapidly. A doctor told me that when his dispensary was raided some of the drugs were used there and then and the dispensary was left in a neat and orderly condition but ampoules were left on the desk. The drugs were used immediately and the whole job was done neatly and all of the remaining drugs were taken.

A doctor not living in this country, tells me he is almost sure that this country is being used as a dump for drugs—that the drugs are coming here and going out for other areas. If this is the case, the Minister would need to get in close and rapid contact with his colleague in the Department of Justice and quite a large drug squad— a specially trained drug squad—should be set up. I think that, at the moment, our drug squad is very limited.

We should have proper clinics for drug addicts. I think we have one in Saint Brendan's. I have a theory—I do not know how right it is—that drug addiction should not be considered as suitable for treatment in a mental hospital. I think it is a bad thing that a unit for drug addiction should be attached to a mental hospital. I think such a unit should be placed in a general hospital. I think that some, one or two or even three, general hospitals in Dublin or anywhere around the country should have special care units for drug addicts and some sort of register should be kept so that a patient who is an addict could not go to Hospital A and get the quota of drugs there which is necessary while the person is being reduced on drugs and then be able to go to Hospital B and Hospital C for similar quantities. I am aware that it is popular to say that we have no drug problem here but, unfortunately, we have a problem.

A short while ago I was at a lecture which was attended by a number of secondary school children. I was horrified to learn from them that they knew where drugs could freely be got in the city. Admittedly, some of them were soft drugs but the hard drugs can also be got. There is no point in codding ourselves that we have no drug problem. They went on like that in Britain and now they have a gigantic drug problem. We must nip it in the bud. It can be done through lectures in the schools and in the universities as well as through films, slides and all these sorts of things which will show the horrors and, indeed, the dangers attached to the taking of drugs. Indeed, I think that very often addiction ends in death, particularly for quite young people. I think that if this could be got across to the youngsters, they would not start to take any drugs. At the moment, I think it is a sort of "something to do" to say "I was taking drugs just for kicks." If these people saw films and heard talks on the subject—if it was got over to them —and if they realised the end that faces drug addicts, they would be very slow to start. This is something that this Bill does not take into account at all.

Usually, when I sit down, I think of all the points I wanted to raise before I got to my feet. I want to mention nurses' salaries and pensions for nurses. Local authority hospitals have a pensions scheme and that is fine for the younger nurses but the position is serious for the senior staff nurses because the pensions scheme did not start until they were senior and getting on a bit. I understand that the pension for matrons, for instance, is very light: that is a pity. I was told of the case of a nurse in a certain Dublin hospital who qualified in 1914 and who is still working with the same hospital because her pension is so small: she is being kept on the staff on a part-time basis. Her pension would be about £300 per annum because she did not get in "on the floor" when the pensions scheme was started. The youngsters who got in at the beginning will get increases but that is because they came under the pensions scheme from the start of their career. The senior nursing staffs who came into the pensions scheme at the tail-end of their career are hard hit. Perhaps it might be possible to pay a gratuity to the senior staff in such instances—the assistant matrons and the matrons of hospitals. I had intended to have some figures for this point which a matron promised to send me but I have not received them so far. I shall pass them on when I get them. They would be quite interesting. Those people have given very dedicated service. They have served prior to this without great pay and certainly twenty years ago with almost no pay at all and they should now get some sort of recognition by way of gratuity or bonus when they are going out on pension.

This debate has proceeded for some time. As Deputy Mrs. Hogan O'Higgins said one forgets what one wanted to say when one stands up to speak and one usually thinks of all the points one should have raised after one has sat down again. I have made some notes to try to avoid that situation if I can.

In considering this whole question of health and in talking about the various Health Acts, we must also consider the views of the medical personnel engaged in promoting good health and we must be grateful to the various members of the medical profession who have taken part in the various commissions which were set up by this Minister and by his predecessor. Today there is a volume of information available to us as Members of this House, and, indeed, to the general public, which was absent heretofore. This information brings home to each and every one of us the vital importance of trying to promote a system of preventive medicine. I will go into that in more detail later on. At the outset I should like to refer to the remarks of the President of the IMA at their recent conference in Killarney. These show that in a way sometimes harm can come from well intentioned ideas. It is often said that a well-intentioned person often does more harm than good and while it is a strange saying it is often borne out by the facts. Dr. Cawley was referring in his address to the conference to certain parts of the British health scheme and he indicated that great harm could befall the community as a result of certain practices under part of the English scheme which is now legalised. He was warning us in advance of the danger which lies ahead in the field of medicine. It is no harm to mention that. As I said, it brings home to us the great difficulty there is in dealing with this whole question of a health scheme both here and in England. I am not saying that those practices would be considered here but it is enough to bring home to us the fact that those practices are taking place very near to us.

Would the Deputy say what the practices were, the practices to which this man referred?

I am not going to mention them in detail. If the Deputy read the newspapers he would see what I am referring to. I do not want to go into the raw details. The Deputy might spare the House that. If the Deputy looks up the daily newspapers——

The Deputy is afraid to mention it in the House.

The Deputy can read about those remarks in the newspapers.

If the Deputy is so concerned about this, why does he not tell us about it? Why hide it under a bushel?

The Deputy will have plenty of scope to make his own speech. I am grateful to him but he is not going to put me out one bit.

The Deputy has been issuing ominous warnings and—-

Perhaps I might suggest that Deputies would address the Chair and avoid making remarks across the floor of the House.

I am sorry. I merely made the remark that this information can be gleaned from the daily newspapers. When he was introducing the Bill the Minister referred to the great cost of various health schemes and he also indicated that expenditure on health has increased from £18 million, away back in 1958-59, to £51 million, if one includes the grants to the voluntary hospitals. Those increases are apparent and real and the Minister rightly indicated that we have made great advances in medicine since then. There is no doubt about that. It was said that there had not been any great advance in the scope of the health services here but this point could be contested on figures relating to general health. If we go back to the 1947 Health Act we find that the figures for tuberculosis since then have fallen dramatically. The death rate is down from roughly 3,500 to 300-odd. The death rate in 1945 was 3,694 and in the 24-year period since the figures have fallen to 341 which is the figure for 1967, the latest date for which I have a figure.

That is a great achievement and I am prepared to argue, no matter what may be said about the 1947 Act or subsequent Acts, that we have been advancing towards better medicine, better preventive medicine and towards better health. Preventive medicine is one of the ways in which we can reduce the mortality rate from infectious diseases. This has been borne out by the figures for infant mortality. As a result of the mother and child health scheme sponsored by the 1953 Health Act, child health has improved considerably. The death rate of infants per 1,000 live births in 1945 was something like 70 while in 1963-64, the latest check I have, the figures were down to about 25 per 1,000 live births. If that is not an advance on two fronts I do not know what people would call an advance towards better health.

In addition to this, recently we have had a report on child health services. In discussing this report at the Killarney conference I inferred from the press that medical personnel, some of them general practitioners and some of them doctors engaged in the public health service, disagreed. Of course, we think then of the old adage that doctors differ and patients die. They disagreed more or less in principle in regard to child health, for example, in regard to the school end of it, some of the county medical officers of health were prepared to argue that public health could handle it better. Against that, the general practitioner or family doctor was prepared to argue that the family doctor was the best man to deal with it. It is a matter of concern to us as Members of the House and members of the general public. The more doctors we can involve in the scheme the better. I suggest this question could be settled easily as between the various elements in the health service in order to work out the best possible scheme for the detection and treatment of disease among school children. Whether it be the general practitioner or the medical officer of health in the last analysis we believe that the patient is the most important person concerned. We hope the various groups in the health service will be able to arrive at a satisfactory solution to this problem.

There are some fundamental aims we should keep in mind in considering the Bill. I believe our aims should be to provide the best child health service we can organise, the best general medical service and the best hospital system we can provide. Certain supporting factors follow such as making the most of our resources in manpower, improving medical organisation and promoting cost consciousness which is lacking in the population because it must be seen and if it is not seen in this House it will surely not be seen outside it. Health calls for high spending and increased spending each year. Various arguments are advanced about how this money could be raised in order to spend it on health but if we want to advance towards better health we must be prepared to spend the money. There is no such thing as a free health scheme. That is a concept which in our conditions we cannot realise. We may as well face this fact in time and not waste our energy arguing about the relative merits of one method of raising the money as against another. The main point is that the money must be found if we are to improve our health services. Those should be our primary aims.

Steady progress has been made in the field of preventive medicine and also in hospitalisation and in the general medical services. The one unfortunate feature of the health services is that whether it arises from what the Americans call the affluent society or not, we do not seem to be able to make any inroads on the mortality rate from cancer and heart disease. We are not alone in this. One could develop this point and say that those diseases are brought about by various factors but it is not our function as laymen to attribute disease to any particular factor; we should leave that to the medical personnel and be advised by them.

This Bill sets out to do several things, to consolidate the law regarding health services and to make a number of changes in the various branches of the health services. It seeks to express in a more definitive way policy regarding eligibility for general medical services. This eligibility question has given rise to great heartburning in the past, as those of us who are members of local authorities are aware, and we know that the cause of the heartburning was that under the present Health Act eligibility was not defined to a great extent. It was left to various local authorities to investigate the means of applicants and decide whether or not they were eligible for admission to the general medical services register. Strangely enough, I do not condemn outright the old system as a number of Members of the House have done because I have some experience of it and I like to see both sides of an argument. From my experience I should like to say that, by and large, the local authorities handle this end of the scheme very well. However, when the home assistance officer was called upon to investigate the means of an applicant he did not have available to him the aids which are included in this Bill. From my experience, the home assistance officers carried out their work in an impersonal way without infringing on the dignity of the claimant. They carried out their work to the best of their ability and tried to arrive at a fair and objective decision in bringing the case to the county manager for his decision.

I was a member of the Select Committee on Health Services set up by this House. That Committee held over 60 meetings during a period of three years and heard evidence from representatives of every branch of the health service, including evidence from county managers.

The present Bill seeks to express eligibility in a more rigid way but, if it does so, it has the advantage of providing for a degree of flexibility. When a system like this is set up and it is necessary to have a formal procedure on appeals, the appeals system must be something like the one we know under the Social Welfare Act or a similar system. I hope that, under the system, the Minister will not find there is a big build-up of paper work and that there will not be long waiting periods. Such a situation would be liable to occur in connection with an appeals system. However, the fact that power is given in another section to provide limited eligibilty should relieve this pressure.

One encounters cases every day in the week which could not possibly be covered by a Health Bill no matter how the Bill sought to define who was eligible and who was not. The Bill also expresses the view that a person should not be denied medical care because of economic circumstances. We have accepted this in every Health Act up to now. We accepted it in the 1953 Health Act and the aim is restated in this Bill. On the other hand, the Bill clearly indicates a rejection of the view that every person should be unconditionally provided with free medical, dental and auxiliary services. This was rejected, as I said at the outset, in the light of the knowledge that we would not be able to have such a scheme.

If anybody wishes to argue on this point he need only look at the British health services. The founder of the social welfare system in England, the late Lord Beveridge, before he died, indicated that the scheme was a failure.

From what is the Deputy quoting?

If the Deputy has the industry to go back over the public press he will see this.

May we have the reference?

The Deputy is not quoting so there is no need for a reference.

Could the Deputy give an indication as to where the statement might be found?

I do not chance my arm.

The Deputy is doing that now.

The Deputy should be allowed to make his speech.

I have great respect for Deputy Carter but I should like him to give us some indication as to where the information he has given may be found.

I will provide the reference for the Deputy later on. At any rate, the principle is rejected here that the State has a duty to provide free medical aid unconditionally for the whole population. It is rejected on realistic grounds in view of our circumstances, in view of our national income per head of the population and in view of our gross national product. The people who talk about this—the hurlers on the ditch—may talk about it for as long as they wish. They can talk about it in the knowledge that they will not have the power or the responsibility, currently at any rate, to undertake the raising of the finances for such a system. Although they postulate this idea, they are well aware that our circumstances would not permit a free-for-all health scheme. There is no such thing as a free health scheme. It must be paid for at some level.

So these people must struggle on?

If the British Government could water down their free-for-all health scheme, they would do so. Strangely enough, indications are that people in Britain are providing for health by way of contracts with insurance companies and not through the State. You must not forget that, whatever may be said about development, it sometimes works out as costly development. The big insurance companies in England can offer very attractive terms in providing for insurance against health risks. The various Health Acts here have been derided and scorned without any reference to achievement. I do not have any regard to an argument which sets out merely to destroy, especially an argument which does not refer to what was achieved under our various Health Acts. The fact that today roughly 90 per cent of the population are eligible for hospital and specialist services is generally overlooked by those critics. The fact, having regard to our size, that one-third of the population enjoy free full medical aid in every sphere is also conveniently forgotten and neglected by those carping critics of our various Health Acts.

One would imagine here sometimes, listening to informed critics, that we had the worst health service in the world. This is trotted out many times. My reply to that is "Go and see. Faraway hills are green." I remember, as a member of the Select Committee on Health Services listening to evidence given by various personnel, by doctors who worked here and who went abroad and, comparing like with like, those men were prepared to argue that under the 1953 Health Act we had as good a service in general as elsewhere.

He must have been in Africa. It was in the Congo he was.

We have here at the moment the Voluntary Health Insurance Scheme under which is covered I think, something like 300,000 of the population. I often feel it is a pity that more of our people who could do so do not join the Voluntary Health Insurance Scheme. The scheme offers value for money. It provides high insurance, if you could put it that way, against ill-health. At the start the scheme mainly dealt with hospital treatment but today it also covers the cost of drugs when it exceeds a certain figure. As well as this there is a supplementary out-patient scheme. We should have not merely 300,000 members enjoying the benefits of the Voluntary Health Insurance Scheme but three times that figure. If we had, the Voluntary Health Insurance Board would be enabled to offer much more attractive terms by way of insurance against ill-health.

I referred to the fact earlier on that we were provided with ample information by the Minister for Health and his predecessors. We had, as I said, the Select Committee on Health Services. We had the 1965 Report of the Commission of Inquiry on Mental Handicap, which I think was issued in April 1965, and we had the Report of the Commission on Mental Illness, which was issued in March, 1967. I cannot but mention here the great progress which has been made in the field of mental illness. I remember not long ago reading a report on mental hospitals in England and I was more or less taken aback, to say the least of it, when I looked at the silhouette of the buildings, the dreary, dark grey outline of the mid-eighteenth-century buildings, which have improved very little in the meantime. I contrasted that with the strides which had been made, for example, in Mullingar Mental Hospital on a very small budget.

I said to myself that the hills were green far away, that one heard about the great strides in medicine and medical matters made in other places but, when one came to relate those to conditions at home, I felt I would be able to answer, if I was asked, that we have a much better system in our own locality. I must say this is due mainly to the motivation of the present RMS with a small staff. He has succeeded in taking away the ugly grey appearance of the building. He has succeeded in introducing everyday activities into the lives of the inmates there. He has succeeded to such an extent that he has brought about the situation that neither lock nor key is needed in the institution.

We are wonderful critics in this country. Lately we have become "super-duper" critics because we do not refer to facts at all. In this way one can say almost anything one likes without being challenged on it. I have already referred to the report, for example, of the group set up to examine child welfare clinics and school health services. All those reports indicate that we have made very great strides in all those branches of medicine.

Even though it may be said that the scope of the 1953 health scheme has not been extended this is a misnomer because within the scheme itself we have made all those advances. All those reports point the way to provide us with the knowledge. Let us equip ourselves with the means of improving those services. This is what those reports are intended for. Certain politicians seem to think it is a great election gimmick to talk about health. I myself am a politician and I am subject to all the ills, faults and failings of a politician but I do not think I would be so shortsighted as to seek votes on a Party plan criticising my own health services unless I had good grounds to do so and unless I could show where the service was seriously at fault.

There are many illnesses at present which we never heard of in the past and which were neglected. I suppose they were taken as the natural consequence of approaching age. Geriatrics is one of the branches of medicine which is going to exercise our minds in the future. It may be argued that rising standards of living and less activity can bring about ageing ailments in life earlier than would afflict an active person. Geriatrics has come to the fore.

I was glad to hear the Minister indicate the progress which has been made in the past number of years in converting county centres for the purpose of dealing with this branch of medicine. I remember when I was a member of the Council of Europe for a very short while being on a visit to a hospital in Switzerland. We were shown some of the advances in medicine, with special reference to geriatrics. The practice there is that the patient is taken into hospital until he is rehabilitated and able to live at home. During our period there we discovered that work therapy made up the routine of the patient's day. The patients in the particular home we visited were from 65 to 80 years of age. We discovered that people who could not use their hands because of arthritis were put to shedding linen. This was done many years ago in the homes by the women who used the thread to sew new garments. At this centre it was discovered that such activity enabled patients to regain limited use of movement in their hands. Discovered also were the other methods used to get circulation moving in those patients and to "free them out", as they said.

When the Minister talks about phased development and phased change this is what he means. This is to be welcomed. The Minister is of the opinion, and so am I, that if a patient has a reasonable home and can be taken into a centre for a period if he is suffering from an ailment like arthritis and can be rehabilitated and sent back to his own home it is to his advantage. That is clinical medicine and is a good way of treating the ailment. In this way the patient will have the best of both worlds. If the patient is able to live at home for a while and even if he has to be taken to the centre again for treatment it helps the patient if conditions at the centre are congenial. Where the grey appearance is abolished the patient will respond to treatment. Patients in other countries responded to such treatment. This is why I welcome the idea of the Minister in trying to promote a number of pilot areas where this particular type of medicine can be practised.

There are a number of other measures in the Bill which I do not propose to discuss in detail. We all welcome the phased change. We all welcome the fact that the system of eligibility will be moved and advanced by the changes proposed in the Bill. The scope of eligibility will be widened to a certain extent and in this way this change will be more or less acceptable to all. The choice of doctor was also a bone of contention in the 1953 scheme. It was argued that those who participated or went into the medical services register were denied their choice of doctor. We recognise the effort the Minister is making in order to bring about this choice in areas where it will be workable and feasible. It will be more difficult in country areas because of the fact that doctors live a distance from each other and to this extent the people will not, for a while at any rate, have the same choice as people living in towns.

When will the people in the rural areas have a choice?

After the general election?

The Deputy has a lot to learn. I advise both Deputy Harte and Deputy Reynolds to remember that.

Annie Oakley made a boast like that, too.

If Deputy Reynolds wants to cross swords with me, he is welcome.

Deputy Reynolds only asked a simple question: when will the people of rural Ireland get a choice of doctor?

They will get it a lot sooner from Fianna Fáil than from "The Hurler on the Ditch". I have heard that empty phrase in this House before. The Deputy talks in slogans and very little else.

"Let Lemass lead on."

And he did lead on.

Deputy Carter should be allowed to make his speech without interruption.

He did lead on, and not blindly. The provisions in the Bill abolishing the specialist charges for out-patients and involving matters concerning the dispensing of drugs will be a success. The Bill in this respect makes for a more civilised approach to the dispensing of drugs without infringing on the dignity of the patient. That was an important point. There is provision in the Bill regarding eligibility for drugs. It is wise to provide this. It is definitive in the matter of means because when one defines "means" rigidly one will realise that it is wise to provide this limited eligibility clause in the Bill so that there will be an avenue of appeal.

The increased maternity grants provided for in the Bill are also welcome because this will back up and promote the mother and child scheme which we brought in in 1953 in the teeth of very bitter opposition, in this House and outside it, not from the Labour Party. We in Fianna Fáil always welcome improvements on any front and let us be wise enough to welcome the improvements provided in this Bill. All of them will make for better standards of community health.

Earlier I mentioned the choice of doctor and this brings me to another point. I am thinking of group practice among doctors which we should do everything in our power to promote. I make special reference to country areas. It was said earlier that two doctors, practising together, could provide a more efficient service. I think that three doctors practising together could provide an even more efficient service in country areas. The more the merrier, because the more personnel we can involve in every branch of medicine, the better.

Before leaving the subject of the general medical services, I should like to say that all the proposals in the Bill, no matter how limited they may be, will cost money. If we genuinely are interested in promoting these proposals for better services we must appreciate that they have to be financed. While certain politicians in local authorities are prepared to bare their breasts and shout about the rates, they forget that the cost of the health services has been increasing year by year and that indications are they will increase progressively in the future.

Up to 1965, roughly, the rates bore half of the cost of the health services. Then the Minister for Health made provision by way of a supplementary grant, which can vary from one per cent to eight per cent above that. I must remind Deputies that every day when one takes up an Order Paper, either in this House or at a council meeting, one finds proposals by members which would cause either the Exchequer or the local authority to spend more money. Against that background, I cannot help but think that the people who practise this calling for services, which they know will have to be paid for, should remember that when the particular service is provided it must be paid for. I cannot reconcile this mentality—every day either in the House or at local authority level we have those calls for more expenditure —with the fact that when the bill is presented they shout: "Goodbye, good luck, we will not pay it."

We object to misspending, not to spending.

The Deputy will have his say.

If the Deputy were in the House as often as Deputy Harte he would know that I have said this.

He is in the House every day.

If he has been here, he has not been listening.

In his opening statement the Minister said that a contributory insurance scheme to cover the middle income group was being examined. If nothing more came of this than the promise that it was being examined, it would be a good idea because it will require people to think of the extent and the scope of insurance and how far it would go, for example, in financing a health system.

I referred here tonight to Lord Beveridge and I refer now again to the British health services. Despite the fact that they have a large industrial population in England and better ways of creating an insurance fund than we have, the insurance fund still had to fall back on the Exchequer. The British worker found himself not merely being pinched on one corn by the insurance fund but nipped on the other by the Exchequer in order to raise taxation to help the fund. This will only be a limited examination of the feasibility of starting an insurance scheme which would cater for the middle income group. That statistics will be produced will be a good thing, even if nothing ever comes of it otherwise. The examination will be revealing in the sense that it will highlight the depth and the extent of the finances needed to support the health services.

Before I comment on hospital services I want to say that we should always hold in high regard the Irish Hospitals Sweepstakes. Over the last number of years—since 1948, I think— Irish Hospitals Sweepstakes contributed £21½ million towards the improvement and building of hospitals. I think the total figure spent was something like £35 million over this period. We should acknowledge our good fortune in having an organisation like this to support our hospital system.

I have read the Fitzgerald Report on the future of our hospitals. Perhaps I should have read it again but, like the child with the school book, I had not got the time. However, I have extracts from it which I shall quote. We would be very shortsighted and it would be a miserable attitude if we condemned the Minister on parochial grounds or through shortsightedness or for political reasons. This report, which was drawn up by 18 eminent members of the medical profession, is an excellent one. Indeed, it is a blueprint to take us into the 'Nineties. It would be shortsighted if because of parochialism or vested interests we set out to condemn this plan. I shall quote briefly from this report. At page 17 it deals with defects in the present hospital system and it says:

There are altogether 169 separate hospitals providing acute medical, surgical and maternity services. Most of them are inadequately staffed and equipped. In county hospitals, the single consultants in surgery and medicine are isolated from colleagues in their fields. Many maternity patients throughout the country have not convenient access to the services of a consultant obstetrician. Inadequate operating theatre, out-patient, laboratory and radiological facilities are keeping patients in hospital longer than necessary. Teaching standards for our medical students and nurses are falling behind as our hospitals fail to adapt themselves to the rapid advances of modern medicine. The older hospital buildings are unsuitable for remodelling while the majority of the modern ones were planned on too rigid and too restricted a scale to permit satisfactory conversion. We realise that available public funds are limited, but even if there were no limitations on financial resources it would clearly be unrealistic and a waste of money to attempt to develop so many hospitals to desirable standards of staffing and accommodation. As we shall show later, the requirements of a modern hospital service have become so complex that we can only meet them by a radical reorganisation of our hospital system involving, inter alia, a considerable reduction in the number of centres providing acute treatment.

The report goes on then to supplement this information and to say that in the opinion of those 18 members of the commission it is highly desirable that our hospital system should be in conformity with the demands of the 1970's, the 1980's and 1990's. As far back as 1963 and 1964, when the regional surgeons were giving evidence before the Select Committee on Health Services, it was contended by them that we could only have a regional hospital based in a university city and that the reasons for that were obvious. This means that we would have about three fully-fledged regional units.

The reason they gave at that time was the fact that in these university cities all the faculties would be represented in the university, and that those hospitals would draw for personnel on the medical faculty, that they would have the specialised advice of the best laboratories, and that those regional units would be backed up by the best appointments, the best aids in medicines and the best personnel. It was said, and postulated, and demonstrated, and, in fact, brought home to us as members of the committee, that those regional surgeons were right in their contention that if we wanted to provide for the future, if we wanted to see our population catered for in the realms of higher surgery, then regionalisation would have to come in one form or another.

As I said previously, we shall be discussing this again at a later stage, but let us not from shortsighted motives, political motives, motives representing vested interests, or just mean carping motives, condemn the Minister's proposal out of hand, because it is going to be phased development which it will take at least 15 to 20 years to complete. A start is being made here on the basis of this report. I am prepared to submit to the House that it is a good start and should not be condemned.

Having listened to Deputy Carter, I am more pessimistic about this measure than I was before I came in here this evening. Deputy Carter was a member of the health committee which was established in 1961 when we re-assembled in this House. Assessing the widespread indignation of the populace at that time concerning the inadequacy of the health services, the then Minister, Deputy MacEntee, was compelled to set up this health committee. I doubt if any committee was in operation for so long, and did so little good. Indeed, it did quite a lot of harm.

It is true to say that this committee which sat for three years called quite a number of witnesses and compiled a lot of evidence. There was a mass of reports, there were tons of waste paper, after that committee, but no tangible progress was made towards the improvement of our archaic health services. Members of my Party, and, indeed, of the Fine Gael Party, on that committee realised that its constitution, its approach and attitude was merely a gigantic stalling device by the Government Party and the then Minister for Health. Our patience wore out eventually and members of this Party resigned as a token of protest against the procrastination and overall attitude of ineptitude on the part of the Minister and the Government at that time.

We then had the White Paper on the Health Services issued in January, 1966, by the late Deputy O'Malley. Worthwhile improvements were contained in this White Paper and it was anticipated that they would be given speedy implementation. Instead of implementing what was contained in that White Paper in 1966 the Minister was not allowed to remain long in office. He was switched to another Department lest the somewhat progressive objectives contained in the White Paper might be given effect to. Nevertheless, I believe that what was contained in this White Paper was of very great benefit to the Fianna Fáil Party.

Deputy Carter spoke about health being used as a political gimmick. He ought to know very well that this is so, because his Party have used health in particular as a great political gimmick at all times. Not the least of those gimmicks was this White Paper on the Health Services. Very many important promises were made to our people in it. It was said that the odious means test for medical cards would be eased and liberalised, if not abolished altogether, that we would have a choice of doctor, and that the outmoded dispensary system would be abolished completely. It is over three years since that White Paper was formulated and, as yet, nothing has been done to achieve its objectives.

We are not told in this Bill that these things will be done. I think it pertinent to ask when they will be done. I am concerned about the remarks of a man such as Deputy Carter who has obviously taken a very deep interest in all aspects of health. He is one of the few Deputies in the Fianna Fáil Party who have shown such an interest and consequently one is bound to take cognisance of what he says in this House. I wonder is this merely another political gimmick because everyone now knows there is a general election in the offing.

Deputy Carter told us tonight that what is contained in this Bill are, in very large measure, long term objectives to be attained in 15 or 20 years time—a gradual implementation of these proposals to be attained in 15 or 20 years time. I wonder does he reflect the views of the Minister in this regard.

I said that only with regard to the hospital plan.

It is one aspect of the Bill. At least the people will be made aware that in respect of one aspect of it, the regionalisation of our hospital services, this is a long-term objective.

No. I am sorry to interrupt the Deputy but I think that what Deputy Carter said was that the implementation of the recommendations in the Fitzgerald Report would obviously have to be phased over a period of ten or 15 years, but not the creation of the regional boards.

I listened carefully to what Deputy Carter said. I believe he was trying to allay certain anxiety on our part in respect of what is contained in the Fitzgerald Report about the regionalisation of the hospital services by saying it would be phased over a relatively long number of years, 15 or 20. This is to take the sting out of a proposal which is so radical in its implications as to close down and wipe out altogether most of the hospitals in this country. Certainly it will close down, and render redundant, and run down, all the hospitals in my county of Tipperary. Not one hospital will remain, county or district, if and when the Fitzgerald Report is implemented.

This Bill is an improvement on our health services in all it contains to implement the White Paper on the Health Services. But the Bill also contains an outline of our future health system as recommended in the Fitzgerald Report which has been accepted in principle by the Minister. This report, which, as yet, has got little publicity, when implemented, will have the most widespread repercussions on the lives of our people because it calls for radical changes in our hospital system. It calls for the establishment of a relatively small number of regional and general hospitals based, at a minimum, some sixty miles apart. It recommends that all hospitals in between, general or district, as the case might be, be abolished.

I appreciate that the eighteen gentlemen who drafted this report are very eminent specialists in the field of medicine, but what they are recommending here is the cold clinical approach to health and hospitalisation with little regard for the human considerations involved. This is a report based on economy and efficiency of the clinical kind that one associates particularly with specialists in the field of health. It may be economically wise to adopt it, but to my mind it is socially imprudent to embark upon a measure which will result in the closure of so many of our hospitals, thereby obliging people to travel considerable distances in order to receive medical attention.

The mind boggles at the thought of a patient, critically ill, having to be transported some sixty miles to receive medical attention at a district, regional or general hospital as contained in these new proposals. There is also the problem of the inability of relatives and friends to visit patients hospitalised so far away from home.

In view of the sacrifices made to build up our hospital services within the various county council areas, it seems a tragedy that such a proposal should be contemplated. When I consider the amount of money expended on these old workhouses, so to speak, these old buildings which we inherited from the British, and the transformation which has taken place as a result of the courage and devotion of county managers, medical men and county councillors and the modern facilities now provided for our people in the hospitals in our counties, the thought of their being closed up, the thought of the crows flying through the windows of these institutions, appals me.

We appreciate fully the need for some form of regionalisation and specialisation. We understand fully the need for economy and efficiency. But this report is too far removed from the real needs of our people; and when our people realise what is contained in this report in regard to our future hospital system, I believe there will be consternation. I do not think it has dawned on our people yet what is contained in this report. It is a wise and astute tactic on the part of a Fianna Fáil Deputy here tonight to say: "Do not worry unduly about this. It will be implemented gradually, phased over a long period of time. This is for the 1970's and 1980's. Do not worry about it in the meantime".

We are being asked to legislate here for the implementation of this report. The Minister and his Government will have the authority to implement it as soon as this Bill is enacted. If and when the Minister gets a mandate for the implementation of the Fitzgerald Report I fear very much—and I would welcome sincerely an indication about this from the Minister when he is replying—that the Minister will commit himself too much to this report and that it will result also in his Department refusing sanction to the necessary monies for the maintenance of our present hospitals, and that we shall see a deliberate policy of the gradual running down of those wonderful hospitals of ours for which we now have responsibility. That is the sinister way in which our health authorities, as we know them, will be compelled to accept this radical change.

I am naturally concerned about what will happen in my own constituency. My primary purpose in speaking here tonight is to indicate to the Minister the outright opposition and hostility of all public representatives of all Parties who have become aware of this report in so far as it affects the hospital services in Tipperary. I want to place on record what this report states in reference to Tipperary hospitals. I will quote now from page 110:

At present there are county hospitals in Nenagh, Cashel and Clonmel. The hospital in Nenagh provides a general medical, surgical and maternity service for North Tipperary while the two hospitals in Cashel and Clonmel combine to provide a similar service for South Tipperary. Our recommendation is that the role of these three hospitals should be changed to that of community health centres. We realise that this recommendation involves leaving County Tipperary without its own hospital service. It has been fundamental to our approach, however, that county boundaries have little or no relevance in the proper organisation of the hospital service and, in fact, many areas can more conveniently be served from centres in other counties. Nenagh is less than 25 miles from Limerick on a fast, main road and we could not justify the development there of a hospital which would duplicate many of the services already available at Limerick General Hospital. Cashel is about 36 miles from Limerick while Clonmel is less than 30 miles from Waterford. We are satisfied that the areas now served by these hospitals can be fully catered for from the hospital centres in Cork, Limerick and Waterford. In spite of the absence of a hospital within the county no potential patient will be at a greater distance than 60 miles from a well-equipped and staffed regional or general hospital (Vide Map 3). There will, of course, be available locally the out-patient facilities provided by the consultant staffs of the main hospitals at the community health centres.

This means, as the Fitzgerald Report so clearly states, the closure of all the hospitals in the vast county of Tipperary. Not only does it mean the closure of the hospitals stipulated here—the surgical hospital at Cashel, the maternity hospital in Clonmel and the county hospital in Nenagh—but it also quite obviously recommends the closure of the other district hospitals as well: the hospital in Tipperary town, the hospital in Clogheen and the hospital in Carrick-on-Suir.

The prospect is an appalling one for my constituents and we cannot be expected to lend our support to such a radical and far-reaching measure as this Bill which places one of the biggest counties in Ireland at the will and pleasure of other districts or regions. As I have said, without boasting, the members of our county council down through the years, irrespective of politics, have been a very dedicated group, particularly in respect of health. As the Minister well knows, we have made vast strides in building up our institutions at Cashel, Clonmel, Tipperary, Carrick and Clogheen. We have not skimped on the monies required for improvements, extensions and maintenance. All our hospitals are fitted with the most modern equipment and we have been blessed with an exceptional staff of doctors, sisters and nurses.

It is difficult to contemplate the closure of a hospital in places like Clogheen or Carrick-on-Suir. Clogheen has no industry of any kind. It has a very high incidence of unemployment and it is noted for its abnormally high emigration. The lovely hospital there is its status symbol. It is the place of greatest social activity in the town. There is an excellent service for the patients. It serves a vast hinterland and anyone who visits it cannot but be impressed by the welcome extended and the happy relationship that exists between patients and staff. Everyone knows everyone else. The doctor knows all his patients personally. There is a wonderful spirit of cordiality and goodwill. That is bound to be conducive to speedy recovery. Yet, here we have a proposal that these people must in future go to Cork, Limerick or Waterford, at the very nearest, for hospital treatment, to become digits in a large institution, numbers in a book, patients in an alien atmosphere, faced with an impersonal approach, to say the least of it. It is a pity that the more human aspect of this problem has not been examined.

It is not good enough to say that this will be a gradual transformation. We challenge this policy in its entirety. We want to nip this proposed transformation in the bud. It is significant that all the people who compiled this report on the future hospital system are all medical men. Surely the layman's point of view ought to be considered? We are the representatives of the people and I believe that I am tonight voicing the sentiments of my constituents in Tipperary and West Waterford. I believe I know their needs, their hopes and their fears in regard to the implementation of a policy of this kind. I lend my voice to the opposition to this measure. I set my face against it. I do not think it is good enough that specialists in any field should impose this kind of policy on our people. I do not think it is good enough that a Government should lend itself to the implementation of this kind of policy without grave and compelling reasons.

I am concerned at the indecent haste with which the Minister adopted this Fitzgerald Report. It is not very long off the printing press. Other reports have been published for years, reports the Government have been loath to implement. On the other hand, they are more than anxious to accept this radical document. We were not unduly worried when we heard the Minister had accepted the report in principle but we are gravely concerned that he should ask us to give it the force of legislation with such speed. I hope I shall never see the day when this is implemented. I would appeal to the Minister to consult with the members of the health authorities on every phase of its implementation and to change this policy wherever the needs of local communities dictate it.

There are other aspects of this matter about which we are concerned. There is the setting up of the health boards, the membership of which will be comprised of not more than half members of local authorities and half members nominated at the instance of the Minister. I understand the Minister has taken to himself the right to appoint the chairman of these boards and the vice-chairman as well. Clearly, the Minister is seeing to it in the structure of these boards that he will have an overall majority for the implementation of his policy at any given time.

I would look with disfavour upon a health policy which was implemented at the behest of the medical men, at the behest of the bureaucrats or even at the behest of the Minister. Our feeling is that whatever health policy we conceive and implement should, in the main, be implemented at the behest of and with the approval of all the people and not of one clique—be it the medical profession or an overbearing group of bureaucrats. Undue Government interference or overbearing control should not be tolerated in respect of the implementation or administration of our health services. The voice of the common people must be heard. It is the people that we are concerned with. We are not concerned, in this Party at any rate, with placating any clique or professional interest. We are not concerned about conceding to any Government undue control over the affairs of our health services. It is appreciated that the more the State subscribes to the maintenance of our health services, the more they will be entitled to have a say and control in the health services. At the present time, the contribution would be approximately 50 per cent. Let us have an equal say but let us not have domination by any one section. We are concerned lest a Minister would bow to the dictates of vested interests in matters of this kind. We would hope, as a Party which has consistently cried out in this House and in the country for a free health scheme embracing all our people, that the community's health requirements would be met without regard to money and that need would be the sole criteria which would apply.

We welcome the improvements in this Bill. We welcome the intention to implement the good things in the White Paper on the Health Services. It is long overdue. We welcome as important the liberalisation of the means tests for medical cards, making clear the eligibility for medical cards and clearing away the ambiguity and doubt which existed as to who was and who was not entitled to a medical card.

Deputy Carter seemed to infer that there was nothing fundamentally wrong with our present health services. He re-echoed the sentiment of the ex-Minister for Health, Deputy MacEntee, who always consistently maintained that our health service— the present health service: it has not changed an iota since his time—was adequate for the needs of our people. That was one of the last sentiments he expressed here before he resigned as a Cabinet Minister. Nothing could be further from the truth. Anyone who tries to maintain that point of view is completely out of touch with the people. It will be denied by anyone who understands the frustration and fear of not being able to afford doctor's fees or to pay for costly drugs or medicines, by anyone who understands the ingrained fear and worry of individuals and families about the prospect of going to hospital and not being able to pay the bill there.

There are countless thousands in this country who have been putting off receiving badly-needed medical attention because of inability to pay the doctor or the specialist. There are others who, having started treatment, are unable to continue the course of medicine prescribed because of the inordinate cost involved. We know these things to be a fact. We know the concern felt about the odious means test involved in granting medical cards. We know how humiliating it is for our working class people to be exposed to rigorous investigation by a home assistance officer—the interrogation, the searching inquiry into their innermost private lives, the compilation of a report on the income of all the members of the household, whether or not they be members of the family. All of that was taken into account and, instead of being granted the medical card, you were told you were virtually a millionaire and should not be looking for a medical card.

Deputy Corish reflected the views of the Labour Party when he said that we regard the means test as utterly contemptible. The people of the lower income group and the working classes generally are the only people to whom these means tests are applied. As he pointed out, in respect of grants for new houses, grants for house repairs, grants for farm enterprises and the like, there are no means tests of this rigorous kind. These grants are given on merit and on merit alone. We wonder why we have held on for so long to this degrading system. Too many people have suffered under this degrading system for far too long.

We welcome the change. We welcome the proposal for a choice of doctor and we hope the Minister will find it possible to have this choice in every area. We appreciate his difficulty in outlying areas and in sparsely populated areas but wherever it is feasible or practicable let us have a choice of doctor. Let us not forget that this was a most demoralising piece of legislation which condemned medical card holders, the mass of our people, to one doctor but if you had money you had all the choice in the world. The medical card holder was tied to the dispensary doctor and the doctor was tied to that patient. Was it any wonder that with this natural ingrained desire for a choice of doctor thousands of medical card holders were exercising a choice and going to a doctor other than the dispensary doctor and paying him?

The lack of a choice of doctor was particularly unjust. It condemned the doctor to continuing to provide treatment for a patient whom he may not have liked and it condemned the patient to continuing to accept treatment from a doctor whom he did not like. Obviously this was not conducive to good relations or good health. The proposal to have a choice of doctor is long overdue. I also hope that something will be done to end the long queues we find at our dispensaries. Of course, the Minister proposes to abolish the dispensaries in certain areas. He has not said precisely how the people will be provided with their drugs and medicines but presumably the doctor will issue prescriptions and the people will be entitled to go to the chemist of their choice.

This has not yet been made too clear. Where the dispensaries are to continue I would ask the Minister to ensure that reasonable comfort will be provided for doctors and patients, that there will be adequate lighting, heating and seating and that adequate privacy will be provided as between patient and doctor. In dispensaries where large numbers are congregating I hope that the courtesy of providing a cup of tea for sick patients, who may be waiting, perhaps, for an hour or two before their turn, will be extended to them, or some little refreshment, especially for patients who have come long distances. This is being done in most of our better-run dispensaries and clinics but sometimes it is forgotten and we hear justifiable complaints about a lack of regard for sick patients waiting unduly long periods in clinics or dispensaries without any refreshment.

Whenever I go to a doctor I am too nervous to sit down. I keep walking up and down.

Yes, you go to a doctor in his surgery but I am talking about people who are obliged to queue up——

——and wait a long time. I agree that people are nervous on these occasions and that is all the more reason why they should get some refreshments. Even a "half one" would do. I also welcome the regard shown in the Bill for the care of the aged, the principle that their hospitalisation should be cut to a minimum and that the emphasis should be on the care of the aged in their homes. Something has already been done along these lines and our very many voluntary organisations are to be congratulated for what they are doing for the aged.

The Meals on Wheels organisation and the many other social groups of that kind are doing great work in bringing succour, relief and comfort to these aged folk. I am glad that the Minister has now facilitated the health authorities by financing to a much greater extent the wonderful endeavours of the voluntary organisations who at great sacrifice, in time, energy, effort and finance, are doing such wonderful work.

In my speech on the Minister's Supplementary Estimate I referred to nurses at some length and I merely wish to reiterate briefly what I then said. I should like to see a greater appreciation of the wonderful work nurses are performing and a due regard for their educational attributes. I should also like them to have reasonable promotional opportunities to progress to the position of ward sister or matron in their respective hospitals. It has been a matter of concern to me for a long time that we do not provide sufficient training opportunities for nurses, and because many of them are unable to gain admission to our hospitals they have to go to England to be trained. This position should not be allowed to continue. There should be designated centres where girls who wish to make a career of nursing would have the opportunity of being trained, in an Irish environment, so that the benefit of their wonderful experience would be given to our own people.

One of the most distressing duties a public representative has to perform is to try to get hospitalisation or proper institutional treatment for mentally or physically handicapped. Improvements are taking place in this field today with the help of the religious orders and very many other dedicated people and it is becoming easier to find accommodation in a proper institution for the mentally and physically retarded. It is easier to find a bed for such people, especially for the mildly retarded, but it is still extremely difficult to secure proper institutional treatment for the severely mentally retarded. It is deplorable that so many of these relatively young boys are finding their way into our mental hospitals. This is not a proper environment for boys of that kind and it is a very black spot on our health services that this position should be allowed continue. The Minister should strive to make a great break-through in regard to severely handicapped children and provide, at least, proper institutional treatment for them. It is also important that more and more employment opportunities should be provided for the retarded. I applaud the great work done in this sphere by voluntary associations in the provision of work for those mentally or physically retarded. I congratulate all those engaged in this great work of mercy and also the employers who, more and more, realise that these trained people, although seemingly handicapped, can be very competent and highly productive. I appeal to employers to engage such boys and girls in gainful employment.

My primary purpose here tonight was to express my views on the Fitzgerald Report in particular and to ask the Minister to be very slow in implementing it. Deputy Carter gave me a gleam of hope when he referred to the phasing of 15 or 20 years but I hope it will be nearer 100 years before all the radical changes in this report see the light of day. I compliment the Minister on introducing the improvements now envisaged. We are a Party of whom it can be never said that we did not provide the necessary money to improve health services. The health of our people is of primary importance and at every opportunity we are pleased to support an advance towards the attainment of the ideal of a happy, contented and healthy community.

At this stage of the debate there is little left to say. While I welcome the attempt to modernise present health legislation, I am disappointed with some of the proposals in the Bill and with some of the omissions. Society demands and expects those who are better off to provide for those less well off. In a Christian community, such as that in which we live, any Government legislating to eradicate many of our ills should be a most popular Government. Deputy Carter said that very often Opposition Members criticise the Government for spending money on health services. For the record, I want to say that any criticisms I have made were not of the spending of monies on health services but of mismanagement and misspending.

When these proposals were first circulated in 1966 we were promised many things. It was not too late to think about the inadequate health services we provide. Comparisons have been made between the British health and social services and those existing here. Again, Deputy Carter went to great lengths to indicate that the British people now consider that their health services and social services generally have failed. I do not know what fairytale the Deputy has been reading: in my opinion, coming from a parish divided by the Border where one part of it has the benefit of the British health services while the other half must tolerate the 1953 Health Act as introduced by the then Minister, Deputy MacEntee, there is, in reality, no comparison. However, one must be realistic. The British health and social services in my opinion are without parallel anywhere in the world. We are a very humble nation and can only provide what we can afford and, therefore, it is unfair to make the comparison I have made. I do so only to put in proper perspective Deputy Carter's arguments.

Deputy Carter would have us believe that the health services initiated by Fianna Fáil in 1953 are the last word in meeting our needs. Far from it. There are far too many people at present in need of specialised care and far too many entitled to and expecting services and not getting them. It is not too late to introduce the present Bill. While I have the utmost respect for Deputy Flanagan, the Minister for Health, I think this Bill is designed more to hit the headlines than to hit the target.

Deputy Treacy concluded his speech by mentioning the mentally handicapped and it is peculiar that I should begin where he left off. It is even more peculiar that I am prepared to put on the record of the House that the Minister is more conscious of the need in this field than possibly any other Minister of whom I know. I believe that the Minister has been left such an impossible task by all his predecessors that he will fail in his endeavours unless something is done quickly.

The mentally handicapped child falls into three categories, generally speaking, the mild, the moderate and the severe. While the mild cases are generally the responsibility of the Department of Education, to some extent they are the responsibility also of the Department of Health. The moderately handicapped child is the responsibility of the Department of Health and much more accommodation is needed for this type of child. This is a type of child that to some extent has been the embarrassment of the family in years gone by. He was pushed into the backroom and forgotten. This is a child who could be trained in home-crafts and who could make some use of his life if given a reasonable chance. We, in this country, have been more concerned with building skyscraper flats with wall to wall carpets in the city than in looking after our retarded children. Indeed, we as Members of this Parliament are not without blame because we agreed to tremendous expenditure for extra office accommodation for this building which, of course, was necessary but we did it at a time when so much money was needed to provide accommodation for the moderately handicapped child.

As I see it, whatever chance a moderately handicapped child has if he is accepted into an institution he will have no chance whatsoever if he is not given this opportunity. Too often, when such a child reaches the age of 16 or 17 years, there is no provision for him. Of the categories I have mentioned, I consider the severely handicapped child as presenting the greatest problem.

We reached the situation in Donegal where the county council was forced to convert a fever hospital into a unit for severely handicapped children under the age of 12 years. The position is that if a child is not admitted to an institution his parents must keep him at home and when the child reaches the age of 16 or 17 years he is forced by circumstances or otherwise to be admitted to a mental hospital, the very place to which he or she should never be admitted.

There is no provision in this Bill, as I see it, which will solve this problem. The situation in Donegal is such that if a child is under the age of 12 years and on a waiting list he will be admitted to Carndonagh Fever Hospital but if the child is one month over 12 years—I might add here that the days of the year have very little meaning for a child who is severely mentally handicapped—he will be kept at home until such time as he will be admitted to a mental institution. I should like the Minister for Health to pay particular attention to this matter.

I had occasion during the past few weeks to ventilate in this House my views on how money is mishandled and misspent. Donegal County Council handed over St. Columba's Hospital, Killybegs, to the Department of Education and the Department of Education with the consent of the Minister for Education agreed to expend £181,000 —the figure which the Minister claims is the final one but which I dispute— on converting the hospital into a hotel training school when the hospital could have been converted into a unit to cater for 60 mentally handicapped children at a cost of between £7,000 and £10,000. This estimate was given to the county council by the county engineer but the proposal was shot down.

The local association for the mentally handicapped were forced to purchase a hotel seven miles away for conversion into a hospital to cater for those children. I must say that the Minister gave a handsome grant to the organisation which is a voluntary one to help them purchase the hotel.

If Deputy Carter misunderstands my position all I ask is that he would be a little more observant or that he would at least read the Dáil debates when they are presented to him. If he does this he will find that I never protested against expenditure under any health headings as long as I was satisfied that the money was spent properly. A sum of £22,000 was spent on the purchase of a hotel in one part of the county and we are spending another £16,000 on preparing it to cater for about 30 mentally handicapped girls while in the northern part of the county, Donegal County Council have spent a large sum of money to help cater for 18 severely handicapped children. Is this bureaucracy going wild? We have a situation in which civil servants——

The Chair would remind the Deputy that civil servants must not be assailed in the House.

The point I was about to make was that the Minister proposes to appoint chief executive officers on the regional boards and I am pinpointing that we will have civil servants making decisions that local county councillors will support. Civil servants are being given far too much authority as proposed in the Bill.

Again, the Chair would remind the Deputy that the Minister for Health is responsible for the administration of the measure.

The Minister will have the power to appoint chief executive officers and other assistants to the regional boards and the point I am making is that public representatives are in a much better position to adjudicate on what is right and wrong having had the facts placed before them. Very often people placed in positions of authority become wildly enthusiastic and, without being too harsh, they indulge in a lot of daydreaming such as is envisaged in the Outline of the Future Hospital System. Page 97 of that report refers to Letterkenny General Hospital. I must say here that I agree substantially with the report except in so far as page 97 is concerned where there is a reference to the district hospitals in Dungloe and Carndonagh but there is no reference to the Lifford hospital. There is a story behind this which might be of some help to the House. It was proposed to close the Lifford Hospital in 1958. I might say it was the first time I became actively engaged in public life. The Department of Health decided they would close Lifford Hospital when the new County Hospital at Letterkenny was opened and the local committee only asked that the county council should wait until the new county hospital was actually opened before they closed Lifford Hospital. That was quite a modest request but it took about six meetings to get a decision. Needless to remark Lifford Hospital is still open and is almost full to capacity any time I visit it. The only protest I have got to make in this regard is that it has been downgraded and is now a unit more for geriatrics than an ordinary district hospital. I have a feeling that bureaucracy is again playing its part in trying to run this hospital down so that it will be closed eventually. If there was no use for it I would be the first to admit it. Like Deputy Treacy, I feel that another look should be given to the matter of closing hospitals and that none of them should be closed until we are satisfied that it is essential to close them.

In his speech the Minister did not say what he intends to do about fosterage. When the Minister had his Supplementary Estimate before the House recently I dealt in great detail with the problem of fosterage. In this country we have children being brought up in criminal conditions. I do not want to go into this in detail because I have already done so, but I am not at all satisfied that the Department of Health are doing what they should be doing to solve this problem. Suffice it to say that every child brought into this world is entitled to family conditions and that a child will grow up recognising right from wrong in a more natural way when part of a family than in an institution.

The Government are prepared to pay as much as £7 10s per week for the maintenance of a child in an institution and we have local health authorities paying as little as 13/6d per week for the maintenance of a child in boarded out conditions with foster parents. I might add that I have already stated, and it is on the records of the House, that Donegal County Council are paying the highest amount in this country at £2 per week. I cannot understand, when there is so much accommodation needed for mentally handicapped children and for geriatrics, why we allow strong healthy children to remain in institutions when they could be boarded out to foster parents.

When I was speaking on the Minister's Supplementary Estimate I mentioned some details and I asked the Minister to let me have the total number of children in fosterage in this country at the moment. I have not yet received those figures and, perhaps, the Minister might have them for me when the Dáil meets tomorrow morning at 10.30. At that stage I would again discuss the question of foster children.

In Great Britain last year the British Government amalgamated the Departments of Health and Social Welfare. I believe it is high time we in this country followed suit. The present health system is controlled basically at local authority level by the superintendent officer who is more a social welfare worker than a health worker. Needless to say 75 per cent or 80 per cent of his work relates to health and medical cards. I believe that, if the Department of Health and the Department of Social Welfare were amalgamated, a better return would be forthcoming.

Deputy Carter, when speaking earlier, said that we on this side of the House criticised the present health structure and he, in turn, welcomed the new Bill. Deputy Carter went to great pains to explain that the Fine Gael proposals for an insurance system would not work. Before he concluded he praised very highly the Voluntary Health Insurance Scheme. This is a change of heart for Deputy Carter because when Deputy Tom O'Higgins, as Minister for Health, introduced the Voluntary Health Insurance Scheme in 1957 it was criticised by the Fianna Fáil Party as being a scheme for the lazy rich. They said it would not solve any of the health problems experienced in the lower and middle income groups. The Fianna Fáil Party contended at that time that this is what would happen. It is only in recent times they have come around to accept that the Voluntary Health Insurance——

Not all of Fianna Fáil.

Deputy Carter must have been speaking for himself when the Minister was absent.

Not all of Fianna Fáil objected to the Bill at the time.

Those who did not object to it should stand up to be counted.

I did not, for one, and the Deputy can read the records.

It is a pretty lengthy debate. Before the Dáil meets at 10.30 a.m. tomorrow I will check to see what the Minister said and it will make interesting reading.

The general tone of the Fianna Fáil speeches at that time was that they were full of criticism.

Debate adjourned.