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Dáil Éireann debate -
Thursday, 1 May 1969

Vol. 240 No. 3

Health Bill, 1969: Second Stage (Resumed).

Debate resumed on the following amendment:
To delete all words after "That" and substitute "Dáil Éireann refuses to give a Second Reading to the Bill on the grounds that:
(a) it fails to provide a comprehensive health service available to everybody based upon insurance principles;
(b) it retains the injustice of financing half of the cost of health services out of local rates; and
(c) it gives, at the expense of local authorities and hospital administrators, excessive powers to central government."
—(Deputy Ryan).

While Deputies on this side of the House have welcomed certain aspects of this Bill, we also find faults in it. One of the things I welcome is the choice of doctor. Very often in rural Ireland under the dispensary system, human nature being what it is, the relationship between a doctor and a patient in the lower income group is somewhat strained. The holder of a medical card is compelled to visit a dispensary doctor if he wishes to avail of the medical system. Very often a person in the lower income group lives close to a dispensary doctor in another dispensary area but has to travel to the home of his own dispensary doctor if he wishes to avail of the service. To my mind that has been an anomaly in the existing health system.

Another fault I find in the system is the imbalance which exists between the various local authorities or health authorities. In County Donegal the allocation of a medical card is decided on different lines from those which obtain in County Meath. I welcome the provisions in the Bill in this respect and I wonder why it has taken the Minister so long to make up his mind when there was such an obvious fault in the system.

What I object to, and possibly what the major part of the country is objecting to at the moment, is the costing of the Bill. I think this Bill will collapse for this very reason. There is no point in spelling out certain principles on which a Health Act can best serve the community. As I said last night, it is useless to hit the headlines rather than the target. For this reason, unless there is a different system of financing organised, the Bill is doomed to failure. Yesterday there were scenes in this city when members of the former corporation marched in protest to City Hall. No doubt, tenants' associations and possibly every local authority in Ireland will be protesting to the Department of Health concerning the financing of the health services.

The ratepayer is saddled with the responsibility of paying for the existing Health Act, an arrangement which has been found to be most unsuitable, and there is no change whatsoever, so far as I can see, in the financial structure of this Health Bill. I am not the first, and I will not be the last, to object to this. I forecast here and now that this Bill is doomed to failure and that it will collapse because of this.

Members of the Government Party have spoken on this Bill and have made comparisons between this country and Great Britain, between the health services available here and the health services available in Great Britain. They have tried to suggest that the British people have now decided that the Health Act in Great Britain has been a failure. This is far from the truth. Before any backbencher over there pays tribute to the Voluntary Health Insurance Scheme, I should like to remind the House that the Fine Gael Party have as one of their policies a scheme based on insurance that would give this country a good health service. It is not by any means comparable with the services available in Britain, but then again, compared to Britain this is a small nation in terms of wealth.

Over the last few years the increase in the cost of the health services here has been astronomical and there is no indication that this will not continue to be the case. For example, the cost of the health services on the rates in County Donegal is 42/6 in the £. This is about 40 per cent of the total rate. It is not so long ago that the health services were calculated to be about 20 per cent of the rate and it is not unrealistic to forecast that in the not too distant future the cost of health services will be 50 per cent of the total rate.

We all know that collecting money through rates is an antiquated and out dated system which was never intended for the purpose it now serves. I am confident that if a scheme such as is envisaged and incorporated in the Fine Gael policy were to be accepted by the Government it would have a better chance of success than the present scheme. I see a lot of good in this Health Bill. There are many shortcomings in the Health Act which have been overtaken by this new piece of legislation. While I welcome the measure there are some shortcomings in it also, and the major one is the costing of it. I cannot see what will be achieved by introducing a new Bill to cover shortcomings in the existing Act if no attempt is made to correct the main trouble at the moment, that is, the financing of it. This legislation is no different from the previous legislation except that hospitals will be regionalised, that the patient will have a choice of doctor and that there will be parity from the point of view of eligibility of a medical card holder.

There are many big question marks as to how the Minister will appoint the regional boards, and I should like the Minister, when he is replying, to clarify the matter of the appointment of the CEO. Again this could mean that the Minister has in mind another army of civil servants and, needless to say, we have civil servants in abundance at the moment. I cannot see that it is necessary for the Minister to appoint a board to control the regional services. He has not stated whether the CEO, the chairman or vice-chairman will have medical experience or, indeed, if they will have any experience whatsoever in the administration of the Health Act. The Minister, for reasons I do not wish to state, seems to be of a somewhat different culture from his colleagues in the Cabinet, and I cannot see him appointing a Party hack. However, it has been done before and there is no guarantee that Deputy Flanagan will always be the Minister for Health. That being so, I can imagine other members of the Cabinet being in that post and appointing a Party hack. This is like appointing a layman to run a diocese and having a bishop to advise him, or getting the local carpenter to run a parish and calling in the parish priest to advise him. I see no point in it and it is just another job for the boys. Time will tell.

I sincerely hope the Minister is more successful than I forecast he will be with this Bill. All this Bill proposes is to remedy the mistakes of the Health Act. It does not deal with the main objection to the present system. Dublin Corporation have been suspended for objecting to the system, and I have no doubt that if Galway Corporation had been controlled by Parties other than the Fianna Fáil Party they would have taken similar action.

It shows how much the Deputy knows about Galway Corporation. If he knows as much about other things as he knows about that, the rest of his speech must be very inaccurate.

I did not hear what Deputy Molloy, the Lord Mayor, said.

It does not suit the Deputy.

I have every respect for Deputy Molloy. I venture to forecast that some day Deputy Molloy will be speaking from the Opposition Benches, that is, if he is returned after the next election; he will be reading up some of the speeches made from this side of the House and he will be agreeing with the Deputies who forecast that the Bill introduced by the Minister for Health, Deputy Flanagan, was doomed to failure because not sufficient attention had been given to the costing of it.

I do not have to tell the Parliamentary Secretary to the Minister for Posts and Telegraphs and the Minister for Transport and Power that the costing of these services is wrong. I have no doubt that when he and Deputy Oliver Flanagan meet in Mountmellick and some of the other towns in Laois during the forthcoming general election campaign, Deputy Flanagan will be taking the Parliamentary Secretary to task on this very aspect.

I was dealing with the appointment of the CEO for the regional boards. This is something which should not be the responsibility of the Minister but of the board itself. When the regional hospital system is set up, if ever, in what way will patients travelling long distances to and from their homes be helped financially to pay for the cost of transport? Will this mean extra vouchers from local authorities? Will it mean an extra ambulance service? Or will there be some ancillary transport service other than the voucher system or the ambulance service? Again, who will pay for it? That is the question. Will this be an added burden on the ratepayers? The matter is not dealt with in the Bill. I hope that the Minister, when he comes to reply, will deal with this matter because, apart from the inconvenience caused to medical card holders by having to travel long distances to regional hospitals, the cost is something that will have to be reckoned with. The Minister should have made some reference to this either in the Bill itself or in the Explanatory Memorandum.

The existing Health Act has been such a failure that it ill-becomes me, or anyone else, to hold a post mortem on it at this late stage. There is, as I say, no evidence of any effort in the new measure to clean away the cobwebs in the existing legislation. The provisions in the 1953 Act in relation to child welfare would lead one to believe that the scheme adumbrated in that Act provided everything that a modern society could desire. There was, in my opinion, a serious attempt made in that legislation to deal with the shortcomings of our society at that particular level. That was in theory; in practice the scheme never worked. I do not know what the picture is elsewhere in the country but I am well aware of the shortcomings in Donegal and I suppose Donegal can be taken as pretty typical of the rest of the country. In Donegal the system has been nothing short of a joke. The county medical officer organises school inspections and the preventive health group go around the schools recommending that teeth should be extracted or that some minor defect in a child should be attended to and that is the end of it. As a father I have had personal experience of being advised as a result of school medical inspection to have a slight defect attended to in one of my children but, by the time the child was called to the clinic, the child had moved on to secondary school and no longer qualified for health services. There is nothing in the new Bill to prevent a continuance of that situation. It promises many things. So did the 1953 Act. I believe this measure is doomed to failure.

The Government, particularly the late Deputy O'Malley, paid a good deal of attention to the 1965 policy document—The Just Society—of Fine Gael. Deputy O'Malley saw a certain good in it from the point of view of education. I have no doubt he, as Minister for Health, would have seen a great deal of good in the Fine Gael policy in regard to health. The fact that it is Fine Gael policy is no reason why the Government should not accept it. They have accepted 99 per cent of the policy we spelled out in regard to education. I would recommend that the Government should give serious consideration to the introduction of an insurance scheme to pay for health services. Costs will inevitably continue to rise and, unless there is some method of financing the health services other than 50 per cent from local rates, there will always be trouble at local authority level. There has been trouble in Dublin Corporation and the ratepayers in Dublin are in a much better position to pay rates than are many of those living on the western seaboard. As well as that, the Dublin Health Authority can provide better services. When one takes this into consideration I do not think it is unfair for me to say that this new Bill does nothing more than deal with the more obvious shortcomings in existing legislation, without coming to terms with the major grievance in relation to meeting the cost. If the Government are not prepared to give serious consideration to this aspect of the problem the sooner we have a general election and a change of Government the better it will be for the country.

I want to intervene very briefly on this Bill. There are two points I wish to make. I welcome the introduction of the provision with regard to a choice of doctor. That provision is welcomed by all my constituents. But, with regard to choice of doctor, there is a problem in my constituency, a problem I should like the Minister to bear in mind. Choice of doctor will operate successfully in built-up areas but it will be of no great significance to people living in scattered rural areas. There are islands in my constituency and there is a large stretch of rural area in Connemara where there will not be a choice of doctor. Down through the years, it has been very difficult to get dispensary doctors to take up the posts when vacancies arise there. For a very long period we may have no dispensary doctor at all in an area with the result that some already overworked dispensary doctor has to cope with two or three dispensary areas at the one time. I make a special plea to the Minister to give special heed to the requirements of such areas. When the posts are advertised, there is not any great demand from the medical profession by way of applications to fill these posts. Therefore, it seems to me that these types of posts are not attractive to members of the medical profession. It is up to the Minister and to the Department to make these positions as attractive as possible for doctors so that we may be assured of a continuity of medical services for our people in the more remote areas.

Some system should be created whereby a doctor who has spent, say, five or six years in a remote area will have priority in his application when a vacancy arises in the city as against the applications of other doctors. A man who has spent years working on an island or in a rural dispensary should be given credit for that service and should be given priority when vacancies arise for key posts in the cities—posts for which they so often apply. I hope the salaries of doctors in these areas will be increased and that the facilities there will be made more attractive for them. It is exasperating for any person representing an area where dispensaries are vacant year after year. Positions are filled on a temporary basis. A doctor comes, stays a few months, long enough to get to know the patients, and then pulls out and goes. It is one of the greatest hardships that people in certain of the dispensary areas in rural Ireland have to contend with.

A new system of distribution of drugs is included in this Bill. I personally welcome wholeheartedly this wonderful step forward. I trust that time will obliterate the terrible memories which people have of the old system which, indeed, is the present system of distribution of drugs where so many people, old and sick, had to go through such a degrading system of queuing up and waiting hours and hours, when they were sick and unwell, to receive drugs which were supposed to help them to recover. The dispensaries were a bad period in our medical history. The dispensing of drugs in these dispensaries has been bad, too. I am glad that, at last, it has moved into a more modern environment and that the drugs will now be distributed through the pharmaceutical agencies to people in retail chemists' shops—people who will better be able to deal with the demand than I think the dispensaries were.

I wish to emphasise that we still feel that the Bill will not cover the position in remote rural areas where dispensaries are not manned on a fulltime basis: I have no solution to offer other than to make these posts more attractive. Young doctors coming out of the universities who spend a year's internship in hospitals might be attracted to work in dispensaries on our islands and in our remote rural areas where there are vacancies and where nobody is coming forward to fill them. I do not like the word "compulsory" but, in the case of Galway, I often feel that the young doctors should be asked to do a year in the island dispensaries or in remote dispensaries such as Carna which has been vacant, on and off, for many years and thus provide some medical service for our people. Otherwise, I do not think there is any complaint I can make about the health services now that the distribution of drugs has been taken care of in a satisfactory manner. Again, I welcome the Bill.

I agree entirely with Deputy Molloy about dispensary doctors living in a rural part of the country. In the west of Ireland there are some dispensaries that have been advertised no less than ten times and there has been no applicant whatsoever for these vacancies. I certainly do not think the Minister for Health can close his eyes to this situation. What he will do about it is a problem but it looks to me as if doctors coming into our rural dispensary districts will have to be paid a higher rate of salary than doctors in urban areas. To be honest, it would not be fair to blame the doctor for not going to a rural area when he can get a post in an urban area because naturally he will have a much greater private practice in the urban area and his income will be much higher than it would be in the rural area. For that reason, I think something should have been embodied in this Bill to show that the Minister is prepared to give the dispensary doctor in a remote area an increase in salary above that of the doctor in an urban dispensary district. Again, as Deputy Molloy stated in relation to the filling of vacancies in urban dispensary districts, it would help if some type of preference were given to applications from doctors who had worked for a number of years in rural areas because the whole thing is certainly becoming a problem. I am sure nobody knows that better than the Minister for Health who represents a rural area as I do and I certainly know that something will have to be done about it.

The Bill clearly indicates a free choice of doctor. Every one of us who represents a rural constituency knows that we shall not get a free choice of doctor in rural constituencies and I do not think that that is being fair. The holder of a medical card living in the remotest part of County Leitrim or County Roscommon or in any part of the west of Ireland is certainly as entitled to the same services as those available to the man living in an urban area. At the moment, holders of medical cards seem to be sort of second-class citizens, according to the doctors. I want to be quite fair here. Some doctors give a terrific service to these people but there are some doctors who do not give them the same service. One very often hears complaints from holders of medical cards about being charged by doctors which, in my opinion, is most unfair. One very often hears complaints from them that they are afraid to approach their dispensary doctor even though they have the medical card. The only way to rectify that situation is by giving a free choice of doctor in the rural parts of the country as well as in other areas. There are some doctors who give a very unselfish and good service to these people. There is a limited number of other doctors and these are the ones about whom public representatives hear complaints. I do not think anybody here would like to see people in the lower income group, the medical card holders, being treated as second-class citizens.

There are a few aspects of this Bill which I should like to have clarified. Is it intended that under this Bill when it becomes an Act financial assistance from the State towards the cost of the health services will be greater than 50 per cent and that local rates will thus be relieved? We are all familiar with the present problem of rates and the cost of health services. We are aware of what happened in Dublin and how the Dublin City Council was abolished. It was a question of the demands being made on the local authority for health charges. Will the means test still be applied? We all know that as far as health is concerned the means test is most unfair because of the way in which the money is provided. Landholders whose poor law valuation exceeds the statutory limit for benefit are asked to make a substantial contribution through their rates towards the health services. The rates at present are contributing 50 per cent of the total cost of these services. These people are debarred from benefit in the same way as the man who is running a small family business, if his income exceeds the statutory limit, is also debarred and again, he is asked to contribute substantially to the health services. This is not fair.

There is limited eligibility in the Bill and is this to apply in the same way to the middle income group? If the 10/- a day charge is to be done away with, what alternative maximum charge has the Minister in mind or what contribution will the people have to make? As far as hardship cases are concerned, such as those involving cancer or mentally handicapped children, or the deaf and dumb, will it mean that these people will be independent or does it mean that the means test will be applied? Deputy Harte mentioned the question of assistance to cover patients' travelling expenses to regional hospitals. Will it be necessary for local authorities or health authorities in rural areas to provide some type of transport service, more ambulances or perhaps a mini-bus, or will travelling vouchers be supplied where the CIE service is available? Again, if that is the situation, will this qualify for recoupment of 50 per cent of the cost? Under this Bill the Minister has power to make a greater contribution than 50 per cent, but even at present he has power to do the same thing and he is failing to do it. What guarantee have we that there will be a higher contribution to the health authorities?

The question of the school medical inspection was mentioned and there is room for improvement here. In my constituency the doctor normally goes to a national school twice a year on average, and if some defect is discovered in a child which needs specialist treatment often two or three years may elapse before that unfortunate child is dealt with. Everybody knows that there is no lack of complaint about the dental services provided for these children. We are told that this is because of the lack of dentists but something will have to be done to improve the situation. We know that no means test is applied to children attending national schools but we also know that people who cannot afford to take their children to a private dentist are getting no service but people blessed with sufficient worldly goods are able to take their children to a dentist for extractions or whatever other treatment is required. Obviously, the victims here are the people in the lower income group. Will this service, which I hope will be improved, be extended to vocational and secondary schools?

Can the Minister make grants available for the building and reconstruction of hospitals or will grants be made available through the new board which is to be established in the place of the Hospitals Commission? There are problems throughout the country in regard to the aged and the infirm who do not require a great deal of medical treatment. In my constituency the emigration rate is very high and we have a number of houses in which there are one or two old and infirm people who are afraid to stay in their houses on their own and are anxious to get into some type of home. In Leitrim we have a list of 45 people waiting to get into these homes, people who are not able to look after themselves. The only comfort they have is that they are visited once a day, or a couple of times a week, by a dispensary nurse. When this board is established will it be able to provide grants for the building or reconstruction of hospitals or homes for these people? I wonder if any progress has been made in regard to the inter-departmental report on the care of the aged?

I should like to know who will prepare the estimate of expenses for health boards. Will the demand on local authorities be statutory or will they have power to vary it? We who are members of local authorities know from experience that the agriculture committee and the vocational education committee may make statutory demands on the local authority. Will the new health boards be in the same position? If so, a very serious problem could arise because in the case of the agriculture and vocational education committees more than 50 per cent of the members of each committee are also members of the local authority but with the proposed composition of the new health boards it will not be necessary for 50 per cent or more to be members of the local authority because while the Minister in the Bill clearly indicates that 50 per cent of the members will come from the local authority he has given himself power to appoint a chairman and vice-chairman as well as the other 50 per cent of the members. It would be unfair if the demand made on the local authority was statutory unless they had more than 50 per cent representation on the board.

I am glad to find that the Bill proposes some change in regard to the issue of medical cards. At present we know that the basis for issuing such cards varies from county to county. When speaking on the Health Estimate I quoted the percentage of medical cards issued in the counties Roscommon and Leitrim and compared them with other counties. I am very pleased to see some reasonableness being introduced into the issue of these cards. It is a desperate situation when you find that the county manager in one county is lenient with applicants for medical cards and in the adjoining county applicants in similar circumstances are refused medical cards. We now have the situation in County Roscommon where over 50 per cent of the people hold medical cards. That is one of the highest percentages in the west of Ireland. The county manager and officials of Roscommon County Council have now decided to reduce the percentage and, as a result, it is utterly impossible to get a medical card for anybody.

Recently I had a case where a man who was in receipt of £6 10s a week and was paying £3 for tablets could not qualify for a medical card in County Roscommon. That is a desperate situation. I am glad to see some firmness being introduced. I should be glad if the Minister, when replying, would say what level of means he has in mind at which people will qualify for medical cards.

I wish to refer briefly to the report of the Consultative Health Council on the general hospital services which was issued some time ago. It is clearly stated in that report that the county hospital in Roscommon will be degraded in status and that it will now be called a health community centre. One wonders what the writers of the report mean by that term. What type of patient is it intended to cater for? Will it now become a glorified home, what we knew in the old days as a county home, a place catering only for the aged and infirm? If that is the situation the Minister should have another look at the report before adopting it. The report clearly indicates that patients who need surgical or any other type of hospital treatment will have to travel to Galway, Castlebar, Sligo and Letterkenny. I do not think that is fair. Before the Minister finally accepts the recommendations I hope he will have another look at the matter and get the views of the local authorities. A number of local authorities send patients to Roscommon County Hospital and a number would be prepared to encourage many more of their patients to go to Roscommon in order to retain the hospital there. It is ideally situated.

I note that the Consultative Council consists of 18 members, 10 of them coming from Dublin, two from Galway, one from Limerick, one from Sligo, one from Tralee and one from Castlebar. I also see that these are all professional men. In fairness to professional men, I do not think they are in a position to advise as to where hospitals should be built. I think that would be a matter for the public representatives, for Members of this House and members of local authorities. I agree that professional people should have the right to make recommendations but when one looks at this Council one finds there are two representatives from Galway and there is a hospital recommended for Galway. There is one representative from Limerick and a hospital is recommended for Limerick. There is one from Sligo and a hospital is recommended for Sligo. There is one from Tralee and a hospital is recommended for Tralee. There is one from Castlebar and a hospital is recommended for Castlebar. One might ask was the setup accidental? Was it fair? Certainly I could not let this pass without comment. The Minister should have another look at the matter.

According to this report, at page 8, paragraph 3, a 200-bed hospital with a surgeon and physician is no longer capable of meeting the needs of the public. We know that medicine has become a very specialised job but if the 200-bed unit folds up we shall find ourselves in the west of Ireland with a dwindling population in regard to hospitalisation just as we find ourselves now in regard to dispensary doctors. The 200-bed hospital has given great service to the people and I am not prepared to accept that report even though it comes from medical men. They have decided to bring the people to the hospital; there is no question of bringing the hospital to the people.

Roscommon County Hospital is a 200-bed unit and the people who go to that hospital are people both from the lower income group and the middle income group as well as people from the higher income group. These people would much prefer to go to a small hospital like this for treatment than to go to one of the largest hospitals in the country. In a hospital such as this people get to know each other, they get to know the surgeons, doctors and nursing staff. There is a homely atmosphere within the hospital. People have been quite satisfied to go to the hospital for treatment so I do not see any reason why the hospital should not be retained. It was well staffed with personnel who gave great service to the people of Roscommon and the adjoining counties. It is regrettable that there should be any suggestion of lowering the status of the hospital to a health community centre.

If this report is accepted and if the situation with regard to regional hospitals continues people living in isolated parts of the county may not go to hospital at all because of distance and so on. Everybody realises that that would be a tragic situation.

I must put on the record of the House the amount of money that has been spent on the surgical hospital in County Roscommon and the number of patients who have been treated there during the past number of years. The original cost of the hospital in 1941 was £138,000. That figure was made up of £46,000 by way of loan which is being repaid by the county council together with the interest and £92,000 by way of grant. An extension to the hospital in 1953 cost £68,276. This was made up of a sum of £53,850 which was borrowed by the county council and £14,426 by way of grant. Another extension was added in 1968, the cost of which was £104,000. This was made up of £52,000 by way of grant and £52,000 by way of loan.

Last year a new laboratory was built at a cost of £3,000. That amount was paid by the ratepayers and Roscommon County Council. Therefore, the total amount spent on the hospital since 1941 was £313,276. This was made up of £158,426 by way of grants and £154,850 by way of loans. Roscommon County Council are repaying the loans with interest over a period of years. It would be most unfair to the ratepayers if the hospital were closed because, ultimately, it is the ratepayers who make the biggest contribution and these are the people who avail of the services in the hospital.

The county medical officer's report for the year 1967 shows that the number of admissions to the hospital was 3,423; the number of operations within the hospital was 1,246 and the number of births in the hospital was 411. There was a total of 830 births in the county that year so that approximately 50 per cent of the children born in the county were born at the hospital. Laboratory tests totalled 6,082 and 2,371 people attended specialists' clinics.

It is very unfair to ask the people of Roscommon now to go to Galway, Sligo, Letterkenny or Castlebar. It appears to me that it is the intention of the Government to wipe Roscommon off the map just as they wiped Leitrim from the map for election purposes. They have put a number of the people into Clare-Galway and a number into Galway so that the aim seems to be to do away with the county. One wonders what is the motive behind all this.

The Minister for Health has a heavy responsibility for the health services and I would like to say at the outset that when he was appointed as Minister for Health he went to the trouble of arranging a visit to every county in the country. That required some effort on the part of a new Minister. The Minister is doing the best he can but, having been sent here by the people, it is our duty to say what we should say and to indicate to the Minister the many problems that, in our opinion, should be dealt with.

There is nothing in this Bill from beginning to end except references to a health board. One may wonder if we have too many of this type of board, commissions and committees. We hear of boards being set up to investigate problems that arise. If much of the work that is being handed over to the proposed health boards were left in the hands of local representatives, the people might be just as well off. Members of local authorities are elected from every area and they are quite capable of going into the council chamber and discussing what is best for the people with the county manager and his officials.

It is my opinion that there are far too many boards. I remember a case of a girl who joined the nursing staff of a certain hospital and who, after six months satisfactory service, was requested to sit for an examination and to go before an interview board. She was successful in the examination but she failed to satisfy the interview board despite the fact that the matron in charge was convinced that the girl would become a very good nurse. That proves that a good applicant may fail to make the grade because of failure to satisfy an interview board. I always remember that case. I knew lads who went through college and failed to make the grade because they were unable to satisfy an interview board. This question of boards is overdone.

There are throughout the country dispensary doctors who are very hardworking men. There may be the odd doctor who may not be co-operative and about whom there will be complaints but generally speaking dispensary doctors throughout the country are always at the beck and call of any patient who needs them. If we are to retain them and to fill vacancies that may arise, salaries must be increased. People may say that a dispensary doctor is very busy, that he is doing well, that he is making a fortune. They do not realise that many of the patients are medical card holders. They forget that doctors are generous when it comes to dealing with hardship cases. They forget that doctors have to travel on all sorts of boreens and bad roads at all hours of the day and night, that they must have a car, that they have to keep a home and pay for domestic help. The salaries of dispensary doctors are not sufficient. Only recently I was talking to the wife of a dispensary doctor who told me if it was not for the practice he was enjoying outside his dispensary area they would not be able to carry on.

The dispensary doctor operating in a rural area has not by any means the advantages a doctor has in an urban area. Doctors in towns like Sligo are in the money as against doctors in small rural areas. It is very disappointing for a good doctor who is doing a good job, working hard in a centre where he would like to live and to settle down, to find that he has not been considered for permanent appointment. Irrespective of who is responsible for this, it is a shame that a doctor should go through so much and that he should be just on a string and that somebody else may be appointed overnight by the Local Appointments Commission to take over his dispensary. That is most disappointing to a man who is out to give of his best. Every doctor today strives to get on the permanent list as early as possible but some dispensary doctors are advancing in years and are still not permanent. That is no encouragement for men to remain in the dispensary service. We may complain when some of them leave the area but the fault is not theirs. The blame attaches to those responsible for making appointments.

There has been a good deal of discussion recently about the financing of health services through the rates, particularly since Dublin Corporation was abolished. That is a very sore point with every local authority particularly when the day of reckoning comes and they assemble in every council chamber to strike the rates. It has often been said that the steady increase in rates must cease some time or other. Dublin has now given the lead. It has often been said that when Dublin leads, the rest of the country follows. There is a danger that many local authorities will adopt the attitude which has been adopted by Dublin Corporation.

In my constituency there is a dwindling population and the people cannot possibly continue to pay increases in rates to the tune of about 10/- per year. I would ask the Minister, when making his final decision on this, to provide that more than 50 per cent of the cost of the health services will be borne by the Department. If the Minister does not face up to this matter, we will see other bodies being abolished and the same thing happening as happened in Dublin. That is not good for the country.

The issue of medical cards represents a sore problem, particularly in my constituency. It would save people from going to the labour exchange if they got a medical card whereby some of the expense incurred by sickness in the home would be offset. People travel perhaps eight or nine miles to sign at the labour exchange for a very small sum of money. If those people had medical cards many of them would not bother going so far for such a paltry sum. They would realise that the medical card would save them a little expense.

Many problems arise in connection with hospital bills. We are often approached by people who have been presented with bills for, perhaps, £50. The people had been attending their family doctor for two or three years and were then advised to go to Dublin, and did so. They did not know that they should be referred to Dublin by their dispensary doctor. The result is they have to pay this big sum of money. In fairness to such people this type of bill should be dealt with through the local authority. If a family have confidence in the doctor who has been attending them for three years they should not have to go to the dispensary doctor before entering a Dublin hospital. That is always a problem where we find people receive big bills. The first thing we ask them is whether they were referred to the Dublin hospital by a doctor. They tell us they went to the family doctor, who advised them to go to Dublin. The result then is a heavy bill which they are unable to pay. Before the Minister finalises this thing, the question of hospital bills should be made easier for such people.

People suffering from severe disability should not be deprived of their allowance simply because there is a high valuation on the home or because the stock may be reasonably up to average. I know of a person who has five or six young children and who is completely invalided with arthritis. As a result of a high valuation and average stock, this young woman was told, on the report we have received, that she could not get a disability allowance. That was very unfair because the return of average stock on a farm is not that high. The home suffers because the young woman is invalided and cannot look after her children. The whole running of that home has been upset. In cases of that sort the rules should be waived. When a person is completely invalided an allowance should be made. There is no hope of any improvement in cases with this type of ailment. The patient will gradually get worse. She is not able to look after the children or cook for the home. She is certainly entitled to a disability allowance. Such a person should not be deprived of a disability allowance because of the valuation of the home or the fact that the stock may be reasonable. Such a person will have to get home assistance.

We come then to the question of mentally retarded children. There has been an application from my constituency to have a convent that is being vacated by an order of nuns converted into a home for mentally retarded children. That has been turned down but there are people pushing for it who have not accepted the answer given by the Minister. There is a deputation coming to Dublin to see the Minister in order to have this convent in County Leitrim opened for old people. I hope the deputation will receive sympathetic consideration. We have in that county a home capable of providing 20 extra beds. That would not put a patch on the need that there is for old people's accommodation at the moment. There are 45 people there but I am sure if there was extra accommodation there would be 45 more only too glad to get accommodation.

I want the Parliamentary Secretary to take notice of this question of Rossinver Convent being considered as a home for aged people. The order is leaving and is going to America. Strong pressure is being put on, and there will be a deputation coming here about it. Throughout the whole west of Ireland there is a serious question of accommodation for aged people in homes. We are told by the county manager that everything is in readiness to proceed with the provision of a new home for the aged in Sligo. The sooner we get it the better. I hope the proposal will not be too long on the long finger. There can be delay before projects get off the ground. The existing home is old with stone floors and stone stairs. The nuns and nursing staff are doing a great job for the people but it is the old home handed down from the days of the county homes. I hope that it will not be a case of being told about the home being sanctioned and then having to wait for a long time. I hope we will get off to a good start and that we will get the people into an environment that will relieve some of the loneliness of being away from home and that, instead of lying 40 or 50 to each dormitory, with nobody to speak to them, they will have a pleasant environment. One would not know they are there at all, but sometimes when one is there they try to speak to you. The sooner we get ahead with this home for the aged in Sligo the better. What has to be done can be done if only the Department will put its shoulder to the wheel. It was done in 1948-49 with the old sanatoria which were levelled to the ground. New sanatoria were erected and we got rid of TB in a short time. If the Department make an effort they can provide bright, happy homes for these old people now.

I must congratulate the Minister on the fine regional hospital in Sligo town. It will be a really bright place in Sligo. The hospital and the school of technology will add considerably to the town. The hospital is proceeding well and should be opened in September. It will be a great help to the town of Sligo and to that part of the country. In Sligo hospital at the moment one can find 19 or 20 people in a ward which was meant for 14 or 15. The hospital is packed to the door. I hope the same thing will not happen again when it becomes a regional hospital and when we get in the poor people from all over the county. I know this could happen as it will be a regional hospital. Patients could be brought in from the surrounding areas and then this new hospital would be packed to the doors. We have three doctors there and the Minister will have no trouble in getting this hospital off to a fine start. There is a surgeon, Surgeon Swan, there and two other fine doctors, Dr. Donovan and Dr. Collins. These three men will make a success of the hospital and of its staff. The Minister will have no trouble getting this new hospital off to a good start.

I should like to refer to the problem of hospital and chemists' bills which are a source of worry to many people. If medical cards were given out more freely we would not have many of those people living in what one might call a state of fear as a result of those bills. Medicinal tablets have reached an alarming price and when people are not able to pay for them they make inquiries and are told they do not qualify for medical cards but that if they make application they could qualify to be described as hardship cases and get the tablets in this way. There should not be any difference between hardship cases and medical card cases and when a person qualifies for one he should certainly qualify for the other. People find it difficult to understand why they cannot qualify for medical cards though they can be described as hardship cases.

There are many who come under neither category and there should be some relaxation so far as the rules and regulations in connection with medical cards are concerned. One feature that should be brought home to the people more frequently is the Voluntary Health Insurance scheme. One often meets people who know nothing about this scheme, where to apply and so on, and more effort should be made to circulate the facts about this matter and bring home to people the advantages of having this insurance against the cost of ill-health and accidents in the home.

It has been said that a health scheme financed by insurance could never work. In a country like this there should be no great difficulty about it. It is not like England which has a population of more than 50 million people. We have only about 2,800,000 people here and a health insurance scheme with all making their contribution should work out very successfully, or at least should get a trial. Today more and more people are going to the towns seeking employment. Putting a levy on those people would relieve this burden of hospital bills and the dread people have of them.

When speaking on the Health Estimate earlier, I mentioned nurses. They are having a long fight to get an increase in their salaries and that in itself is responsible for hospitals finding such difficulty in getting nursing personnel. Throughout the country retired nurses are asked to go back into the hospitals because young nurses who have trained elsewhere find they are not able to come home and enjoy the same rate of salary here. It is taking so long to bring this whole matter to finality that many of our nurses have left before anything is done. It creates great discontent among our hardworking nurses who do such an excellent job. I hope the Department will bring this to a conclusion and let the nurses have increased salaries without delay.

Quite a number of boys and girls are placed in schools for mentally retarded children throughout the 26 Counties. They have to travel long distances, for example from Donegal to Waterford and from Sligo or Leitrim to Galway. Some arrangement should be made with the parents about the transport of these children, whether they are entitled to transport or not. I recently had a letter from the father of one of these boys. He had not time to apply for a voucher and had to hire a car which cost him £24, to go to Waterford to fetch the boy home. The cost to CIE would not be much, because many of their buses are going empty. I think vouchers should be issued in good time to people so that they will not have to go to county council officers to see about them. When the schools are closed the vouchers cannot be obtained and people have to make their own arrangements. For people with mentally retarded children, and with perhaps limited means, it is too bad that they should have to go to the expense of paying for transport to collect their children. It is good for the children to know that they are coming home on holidays. In days gone by they never came home. I feel that vouchers should be issued to those parents to go and collect the children.

There is a crying need for speech therapists. The Department should try to get people qualified and place them where the demand is. We have a number of people in Sligo anxious to have a speech therapist there but none is available. It is hoped that some will qualify this year. I would ask the Minister to have a class in Sligo for children who need speech therapy. It could make a big difference to boys and girls going out into the world to have their speech improved.

The Health Bill is intended to extend and improve the present health services. We must admire the present Minister for Health for the length of time he spent visiting every local authority and health authority in the country and meeting the various interested people, such as chemists, doctors and specialists, before he introduced the Health Bill.

We all know, particularly those of us who are members of county councils as well as being on the Government side of the House, that the cost of the health services is one of the things that has been debated up and down the country in the past few months and will continue to be debated. For that reason I should like to put on record here that I agree with the Minister that at the present time we could not afford a free-for-all health service. Anyone with a little common sense who can add two and two knows that the economy of the country could not afford it at the moment. The cost of the health services for the current financial year is in the region of £50 million. The Minister estimates that to give a free-for-all service would cost a further £20 million.

This would not be free because the taxpayer and ratepayer would have to pay for it. At present the taxpayer contributes approximately 54 per cent of the cost of the health services and the ratepayer 46 per cent. If we give a free health service it is only those in the very high income groups who will benefit because under the provisions of this Bill, and even under the law as it stands, 90 per cent of the people will qualify for hospital and specialist services and 30 per cent, it is estimated by the Minister, will have medical cards. In a county like my own at the moment 47 per cent of the population have medical cards and under the provisions of this Bill there should be a substantial increase in that due to the fact that the total income of a household will not be taken into account. One of the complaints about the old Health Act was the fact that to qualify for a medical card the total income of the household was taken into consideration. A man might be earning and have two sons of 17 and 18 earning as well. To assess whether or not that man and his wife were eligible for a medical card the total income of the household was taken into account. One of the desirable provisions of this Bill is that only the income of the husband and wife will be assessed.

Another desirable provision is the free choice of doctor. This is something that has been complained of in this House and in the various county councils and at meetings of many organisations all over the country. I agree with the Minister that in rural areas a choice of doctor will not be as easy to have as some people would suggest. It will be difficult to get doctors to stay in dispensaries in remote areas unless there is some incentive. In these modern times I feel the only incentive that will keep anybody anywhere is money. Therefore, a special grant or salary will have to be paid to doctors to help keep them in remote rural areas. Choice of doctor is quite a simple thing in towns where there are two or three doctors, but again who will decide what patients will attend Doctor X and what patients will attend Doctor Y? These are matters of administration which, in my opinion, will cause a certain amount of difficulty.

One problem that annoys every member of a local authority and about which he has to make representations to the county manager year after year is the cost of drugs and hospitalisation for long-term patients, particularly those who are physically or mentally handicapped. There is an improvement in this Bill and the Minister is to be complimented on the provision that, irrespective of means, people born disabled either physically or mentally will get free hospitalisation and free drugs and treatment. Nobody could object to this provision because it is hard enough on parents to have a child born physically or mentally handicapped without having the added worry of having to pay the very high cost of drugs and hospitalisation. I note also that the means test for disabled persons' maintenance allowance is to be eased. In other words, when a county manager and his officials are assessing the means they will not take into account the full income of the parents. In the past they took into account the earnings of the other members of the family. It was somewhat similar to the assessment for eligibility for a medical card. In this case there is an improvement.

I cannot understand why this disabled person's maintenance allowance is attached to health. It often struck me that it should come under the social welfare code. We have contributory and non-contributory old age and widows' pensions. We have unemployment benefit and we have unemployment assistance. We have contributory national health benefit. I cannot understand why we have not got national assistance in the form of disabled persons' maintenance allowances under the social welfare code. That is one aspect of the social welfare code which I think should be extended. I am not now referring to social welfare except in connection with disabled persons' maintenance allowances.

Take a child who is handicapped mentally or physically in a family of three, four or five children. When he reaches the age of 16 years, and the other members of the family have moved away, he must feel: "They are gone and I am a burden on my parents or my brothers and sisters." There should be no means test in the case of a child who is disabled physically or mentally when he reaches the age of 16. I mention the age of 16 deliberately because, up to that age, the parents are in receipt of children's allowances. If the other children are younger they are not earning and, when the disabled child reaches the age of 16, he must feel that he is a real burden if he is not severely mentally handicapped. I sincerely hope that in any extension of our social welfare code the dependent person's maintenance allowance will be taken over by social welfare, that there will be no means test, and that those who are physically or mentally handicapped will get some assistance from the State This is something we would all desire to see coming to pass.

I will not go into detail about the regionalisation of the health services except to say that there has been some complaint that if we regionalise the health services we will lose the local touch. Under the Bill we will still have the local committees which I presume will be the county councils. Apart from that, we will have representation by the county councils on these regional boards.

Is there a health committee in the Deputy's county?

There is.

Do they do anything at all?

This is the only time we get the doctors in to have a chat with them. Our county council is the health authority and we have a consultative health committee. At county council meetings the only doctor present is the county MOH. When he is present at council meetings, strictly speaking he is not a doctor. He is more or less an official of the county council and, as such, he is bound by a lot of regulations and a lot of red tape. When we have a meeting of the consultative health committee of the county council that means the dispensary doctors are brought in.

Only one is brought in.

We bring in the dispensary doctors from the whole administrative area of the Carlow County Council.

They do not order their business properly in Deputy Tully's constituency.

The consultative health committee have no power good, bad or indifferent. When the Minister hears about this there will be an awful row.

I am putting it on the records of the House, where the Minister can read it, that when we call our consultative health committee together, we bring in the dispensary doctors, the county MOH, and the officials of the health section of the county council. We meet and have discussions. This is what I was going to refer to when Deputy Tully brought up the point. The beauty of a regional health board is the fact that we will have people from the medical profession on it. At county council meetings administration is discussed, and the ordinary administration of the health services at local level is discussed. It is unusual to have a doctor on a county council although there may be a few. At meetings of a board where we have representatives appointed by the medical profession we can have down to earth discussions on all aspects. This is the advantage I see of having a board and local committees as well.

If Deputy Tully wants us to come down from Carlow to Meath to help out with the formation of a consultative committee, we will be glad to do that too.

I will put down a question for the Minister. They are not entitled to have all the dispensary doctors attending meetings of the consultative committees.

Deputy Nolan will advise Deputy Tully about his committee.

This 1969 Health Bill has been awaited for a long time and, now that we have it, it is very disappointing and makes very gloomy reading. We had expected that there would be something revolutionary and something worthwhile in it. As a matter of fact, I think the Minister has lost a great opportunity of putting himself in the forefront of his Party by bringing in a worthwhile and fully comprehensive Health Bill. He has missed this opportunity because, to my mind, he is just stepping in cautiously to improve what we already have. Looking at it generally, I think this Bill is not necessary at all, because a few amendments of the Health Act would have given us the same suggested improvements. These improvements are very small to my mind.

The burning and controversial question is the question of the financing of this Bill. In view of the attention which had been directed to this very controversial matter over the years, we had hoped that the Minister would bring in some other system of financing the 1969 Health Bill. Unfortunately, he has not. He still expects the ratepayers to foot 50 per cent of the Bill, and perhaps a little more at times. He thinks they are the proper people to pay. The position has become so serious, as we all know on every side of the House, that the health service charges on the rates are becoming unpayable. They are an average of something like 40/- in the £ now. They are from 33/- to 45/- in different areas. We know they will continue to rise despite the fact that when this charge was first introduced in 1960-61 we were told it would be only a few shillings in the £.

I know we cannot have a service without paying for it. To add insult to injury, the Minister suggests that the new hospital boards should take over full power and he still expects the ratepayers to foot 50 per cent of the bill. The Minister will have 50 per cent of the members as his nominees plus the top men in the medical profession. Medical men are excellent in their own profession but I doubt if they are the proper people to put in charge or partly in charge of these regional boards.

We would not begrudge the Minister taking over control of the health services if he were financing them. The boards must get permission for expenditure; in other words if there are some new drugs, even pills, it is suggested that permission must be obtained not alone from the Minister but from the Minister for Finance before they are purchased. The people of my constituency are very disappointed at the approach of the Minister on the financing of the health services. Action has been taken in Dublin in regard to the rates. I do not think that is a good thing, but the other local authorities may be forced into it because it will not be possible to pay the extremely high rates, 50 per cent of which in most cases are due to health charges. The health services should be made a national charge instead of a local charge, thus spreading it over a wider field.

I remember on more than one occasion in my own local authority in Cork we had discussions about the financing of the health services. We suggested that the services could be financed by means of a voluntary health insurance scheme. We were immediately shouted down and told that we wanted to hand over completely the running of the health services to the powers that be. That may have been the case, which I doubt, but now the Minister has the audacity to take full control on the basis of a 50 per cent contribution. Not alone is he appointing half of the committee but he reserves to himself the right to appoint the chairman and the vice-chairman.

Regionalisation, to my mind, is a first cousin of centralisation. It seems to be an obsession in the minds of the Government to regionalise this and regionalise that. There is rationalisation and centralisation. A decision was made some time ago to decentralise, to take some of the Departments down the country, but I do not know what progress has been made in that direction. Regionalisation is only another move towards centralising the services.

There is very little spelled out in this Bill. There are vague references here and there, such phrases as "as far as practicable" or "the Minister shall as may appear to him appropriate". There is nothing cut and dried. A great deal is left to the imagination. While I am sure all of us would welcome a change in the dispensary system, that is not spelled out either. The choice of doctor is welcome but, while we express pious hopes that it will work out, there is nothing definite to indicate that the dispensary system will be wiped out or that dispensary doctors will be put in a different category in relation to their services to the public. The Minister as yet has not made any agreement with doctors as to how they will be paid for their services. If the full co-operation of the medical profession is not forthcoming it is very doubtful if the Minister can hope for the success of any Bill.

The success or failure of this Bill depends on the making of regulations. As we know, regulations can make a success or failure of any Bill or section of a Bill. If it is possible, referring again to the dispensary system, that choice of doctor may result in speeding up the appointment of doctors in those areas which have been without doctors for years, then I approve the suggestion. There have been temporary appointments, but the doctors filling these do not as a rule live in the locality and that causes hardship and inconvenience for those who need their services, particularly at night. The Minister should give serious consideration to that aspect of the matter in this Bill.

I feel very strongly about the downgrading of county hospitals, particularly the downgrading of Mallow hospital. It serves a very wide area. Everything possible has been done to make that hospital an up-to-date hospital. It may not be comparable in all respects to a real county hospital but the service provided there is second to none. The recommendations of the consultative body have been published. This body was constituted of 18 members, nine of whom were from Dublin, two from Cork and seven from the west. Reading the names one appreciates that they are all very eminent in their own professions and I am sure they are all very well qualified to discuss the problems relating to their own professions, but some of their recommendations are quite revolutionary. My first reaction, when I read the report, was that it was typical of the sort of production civil servants throw out to the country without any consideration at all of the effect their suggestions may have on the people concerned. That was my first reaction. I have since studied the report pretty carefully and I have found no reason to change my mind. At page 20 the following appears:—

We are satisfied that the present structure of our hospital organisation is outmoded and is now a hindrance to good medicine, good teaching and economic operation. We believe that if it is to be adapted to meet fully the requirements of modern medicine this can be achieved only by radical changes involving a departure from many long-established concepts in regard to organisation, staffing and the operation of hospitals.

What does that mean? It means depriving country people of the service they enjoy at the moment, the service to which they are entitled and for which they pay. These gentlemen want to bring the patients to the big cities. Regionalisation and, its first cousin, centralisation. These are supposed to be the cure for everything except, possibly, ill-health. This suggestion will, in my opinion, make the position more confused and result in a worse service. "It is now a hindrance to good medicine, good teaching and economic operation": I do not think these people are qualified to talk about economic operation. That is a matter for administrators. But, even if they were right, they are wrong in their approach and I assure the Minister he will have the hell of a fight on his hands in Mallow and North Cork if he accepts the suggested service provided by Cork city and Limerick Regional Hospital. These gentlemen have no idea at all of what County Cork is like.

The area served by the North Cork Board is bigger than some of the counties in the rest of Ireland. Are people, under this suggested scheme, to be put in the position of having to take father, mother, sister, brother or relative 60 or 100 miles to a regional hospital? Are these unfortunate patients to be dumped into cars, because an ambulance will not be available, in the middle of the night and hiked off to Limerick? Is that the idea of a good service? It will certainly not be good for the patient. That sort of thing damns this Bill. On page 30 there is a wonderful map of Ireland with the hospitals spaced out. It is a work of art. I am sure those concerned got the map first and then carefully marked it out before ever they made their recommendations.

Not at all. They divided the hospitals between the members of the board.

It is a lovely map. Judging by it, they are looking after the cities fairly well. Again, it is a case of anything being good enough for the old fellow in the country. That is the approach. Referring to Mallow County Hospital at page 109 the following appears:

Mallow County Hospital is a 98-bed hospital in a modern building providing a general medical, surgical and maternity service and staffed at consultant level by one surgeon and one physician. The hospital is 23 miles from Cork and is serving an area from which access to Cork is easy. The area north of it, around Rathluirc, is convenient to Limerick. We recommend that the role of this hospital be changed to that of a community health centre and that its acute hospital functions be transferred to Cork and Limerick hospital centres as appropriate.

What is the reference please?

Paragraph 9.43, page 109, of the FitzGerald Report Outline of the Future Hospital System. We are told that the hospital is serving an area from which access to Cork is easy. Access to any place is easy now. However, they do not consider the distance. Some parts of that area are well over 70 miles from Cork, it might be considered easy of access to Cork, in the sense that a car can be sent for and the patient will be brought there but consider the effect of a journey of 60 or 70 miles in the middle of the night on an unfortunate person who requires an operation, and the consequent strain on the strength of the patient.

The Minister has a tremendous fight on his hands in this matter. Already, he has had about 10,000 signatures from people all over that area protesting against the suggested closing of the hospital. He is trying to stave them off. He is promising to go down to discuss the matter with them. He said he would go down after Easter but he has not come down as yet.

He did not say which Easter.

The Minister has a difficult problem on his hands. I wish I could congratulate him in respect of something which has been well done or in respect of some improvement. Unfortunately, I can see nothing in this measure that could not have been done by way of amendment to the existing Act. This measure is unimaginative, gloomy and disappointing. If that is to be the approach to our future health services then God help us.

(Cavan): In order to assess the value or the merit of this Health Bill it is necessary to have a quick look at the recent and not so recent history of health and of the health services in this country. When the Health Act of 1952 was introduced and enacted, it was quite apparent that it was an unsatisfactory measure—unsatisfactory in two aspects (1) that it was continuing the Victorian health services which had operated here for so long and (2) that the method of financing the health services provided in that Act was entirely unfair and would lead to a very severe charge on local rates notwithstanding the fact that the then Minister for Finance, Deputy Dr. James Ryan—now Senator James Ryan—assured the country that it would not cost more than 2s in the £. However, it soon became apparent that the criticism levelled at the Health Act of 1952 by this Party was justified. This Party continued to complain about the services provided by that Act and continued to complain about the mounting charge on the rates.

When, later on, Deputy T.F. O'Higgins was Minister for Health, he introduced the Voluntary Health Insurance Scheme which, at that time, was criticised by the Members of the present Government. It has since turned out that that Voluntary Health Insurance Scheme gave and is giving absolute satisfaction to those whom it was intended to serve. The categories covered by that scheme are loud in their praises of it. The numbers of people joining it are increasing. Deputy O'Higgins, at that time, also proposed a contributory scheme to cover the rest of the community other than a certain defined category who would be spelled out in the Bill and who would not have to make any contribution.

Unfortunately for the country, Deputy O'Higgins's scheme did not materialise because there was a change of Government. Between 1957 and 1961, the defects and shortcomings of the Act of 1952 became more apparent and, indeed, in the 1961 election campaign, health was a very live issue. Immediately after the 1961 general election, following a motion in this House, the then Minister for Health, Deputy MacEntee, more or less conceded that, at that stage, the health services were totally inadequate. He set up at that time a Committee of the House to advise on the health services and to make recommendations for the improvement of the health services. Speaking subject to correction, that Committee of the House was set up in 1961 and a time limit of six months was imposed on it to report to the House. The fact of the matter is that nothing was ever heard from that committee other than a request that the time given to it for reporting should be extended. It had many meetings and, again, this Party submitted detailed proposals to that committee for the improvement of the health services. Due to the conduct of the Government Members on that committee it is fair to say it broke up in disorder, died roaring, and nothing has ever been heard from it and it never reported to the House.

That was the prevailing situation in regard to health services after the Government had been in power from 1957 to 1965. All that time the health services were the subject of criticism and complaint from this side of the House and the subject of promises from the other side of the House. At last, in 1966, the Government published its White Paper on "The Health Services and their Further Development" and that White Paper was debated here in January or February of 1966. This Party, and indeed the Labour Party, considered the proposals contained in that White Paper quite unsatisfactory and totally inadequate. We were led to believe by the late Minister for Health, speaking on behalf of the Government, that legislation would be introduced in the autumn of 1966 to implement the proposals in the White Paper. Again, speaking with the authority of the Government he said he hoped that those proposals would be in operation by the end of 1967.

It is quite obvious to me that Government policy and the attitude of the Government towards health services made it impossible for the late Minister to implement the proposals contained in this White Paper, unsatisfactory and inadequate as they are. I believe that if the late Minister had been allowed by the Government to do so he would have at least introduced a Health Bill of some description and would have had it enacted, but I believe he was so frustrated as a result of Government policy that he was glad to get out of the Department of Health. It is a fact that he did act promptly when he took over a new Department.

As I said, legislation to implement the proposals in the White Paper was promised in 1966. There is no doubt that between 1966 and 1969 there has been a very considerable change in the outlook and approach to social welfare, social services, to standards of living and to living in general, not alone in this country but throughout the world. At last, three years after this was promised, we have the 1969 Health Bill introduced in an effort to implement Government policy. One would have expected that with the lapse of three years and with the change of outlook towards social services—and health is one of our principal social services—this White Paper of 1966 would have been improved upon and would have been brought up to date, but what do we find? We find that we have not an improvement on what was promised in 1966 but a watered down edition of this three-year-old White Paper, watered down in a number of respects, with which I shall deal later in detail.

This is typical of the Government's thinking in regard to social reform in general. It is evident that having been in office for so long they are prepared to sit back and give the minimum rather than look forward and move with the times. In so far as this Bill proposes improvements on the present health services, it is welcome. The regional hospitals will provide a better service than the small county hospitals. There are a number of other moves in the right direction but they are too little and too late.

For example, the Minister has written into this measure that the maternity grant, which was fixed at £4 in 1953, is to be increased to £8. Surely that is not before its time? How long will it remain at £8? The Government are very fond of doing things by regulation and this is one thing, one would think, that could be brought up to date from time to time by way of regulation and that we would not have to wait for a formal Act of Parliament to be passed by this House and the other House to do so. I only mention the maternity grant to show how little the Bill is doing. When the Minister finds it necessary to mention a thing like that in his introductory speech it shows the small way in which the Government are going about things. Surely if £4 was considered any sort of grant in 1953, it is long out of date now having regard to the change in the value of money and to the increase in the cost of living? I am only dealing with this issue at this point to show that the whole Bill is outdated and long overdue.

My three principal criticism of the Bill in a general way are that it contains the objectionable means test which is really the old red ticket brought up to date——

The Deputy said he would give instances to show that the Bill is a watered-down version of the White Paper.

(Cavan): In my own good time.

I shall look forward to hearing them.

(Cavan): I had only started just before the Minister came in. I think it is apparent under the heading of choice of doctor —but I shall come to that. My three principal objections are that it contains the objectionable means test which has come down from the last century; that there is not a real choice of doctor and that the language dealing with the choice of doctor is certainly less specific and more ambiguous than that of the White Paper, and that the method of financing the proposals in the Bill—50 per cent as a charge on the rates—is outrageous especially when we see that an effort is being made to take some of the control from the elected representatives and hand it over to the Minister and to the Custom House.

Nothing gives greater trouble to patients, administrators and public representatives than the means test. I think no system of medicines based on a means test is satisfactory in this country. As a nation we are not constituted to fit into a means test. The application of the means test seems to vary from area to area and county to county. For example, in County Cavan which is a poor county, something like 29 per cent of the people have health cards, whereas in Carlow something like 47 per cent enjoy that privilege. That is hard to understand. Further, some people who are entitled to general medical cards find it difficult to get them; others who appear to be better off are able to get them. I am not alleging political patronage or "pull" but I say that the system is wrong and impossible to operate and as long as people can drive a coach-and-four through it they will do it.

A person who goes into a local hospital may require treatment for several weeks. All the time he is there it is a worry to him and his relatives whether he will have to pay for treatment, whether he will be in the lower or the middle income group or whether he will be treated as a hardship case. That is part of the unsatisfactory means test. This test should be abolished.

I fully appreciate that medicine and health services must be paid for. I shall deal with that later. The Fine Gael Party proposed a contributory scheme for the health services. I do not know if the Minister has given that adequate consideration. Certainly, it was spelled out in detail for him and for the committee set up by Deputy MacEntee to which I have referred and which never reported.

Would the Deputy give me the financing of the Fine Gael scheme?

(Cavan): It has been given and is on record here. Deputy O'Higgins spelled it out in black and white.

I got six different versions from the Deputy's side of the House in the past two months. All I am asking the Deputy is to let me know which of them he supports.

(Cavan): It was spelled out by Deputy O'Higgins to the committee set up by Deputy MacEntee——

Could I have it now?

(Cavan): Deputy O'Higgins has put it on the records of the House time and again. There is no doubt about that. Does the Minister believe that the present means test is satisfactory? Does he suggest it is equitable and workable, that it gives satisfaction either to county managers charged with the operation of it or to the unfortunate patients who must avail of it? It is nothing more or less than an extension of what was the old red ticket.

In the White Paper it is stated that the greatest practicable choice of doctor would be given. I am quoting from the Minister's speech and I am assuming that he quoted the White Paper directly. When we come to the Bill we see that the choice of doctor is to be given "in so far as it is conto sidered practicable..." The Minister, dealing with this delicate subject, said that it would not be possible to provide a choice of doctor everywhere. He specified the Aran Islands and I agree with him there: it would not be possible to provide a choice of doctor in the Aran Islands, but it is possible in every place where there are two doctors. I believe the language used in this Bill is not only a safety valve to deal with cases where it is impossible to provide a choice of doctor but that it is also a way out. If the Minister had written into the Bill that the health boards must provide a choice of doctor where possible, or even where practicable, it would be another matter; but here we have this lovely Civil Service language saying that it is to be provided "in so far as it is considered practicable..." Could any better language be found for watering down the White Paper which spoke of the greatest practicable choice of doctor?

The Minister says that he has another objection to the dispensary system and he referred to a comment I made about the old dispensary system being carried over. It is obvious in so far as a choice of doctor is concerned that the old dispensary system will be carried over in certain areas. There is no guarantee in the Bill to the effect that the only real condition precedent to a choice of doctor will be the availability of a choice of doctor. If that was put in there would not be so much ground for criticism.

Another criticism of the dispensary system is that dispensary patients, as they were then called, were seen in some out-of-the-way isolated building, no better than an outhouse while other patients were seen elsewhere. The Minister, in his speech, said that patients would normally be seen in the doctor's premises but that the health board would have power to make accommodation available to general practitioners in clinics or health centres. I do not know what that means. It is wide enough to mean anything. I see also from the Minister's speech that vacancies for doctors are to be filled by public competition.

I do not fully understand that and, perhaps, the Minister, when he is replying, would explain it for us. I thought that choice of doctor meant that the services of any doctor who was qualified to practice medicine and who wished to participate in the scheme could be availed of by patients who wished to do so but apparently the doctors participating in the scheme will be in the nature of dispensary doctors or, State doctors at any rate. It seems, therefore, that there will only be a limited number of doctors available and that any qualified doctor who wishes to join the scheme will have to be recruited by the Minister.

Although we are discussing this Bill in the dying days of this Dáil it is difficult to see when, if ever, the legislation with regard to choice of doctor will come into operation. The Minister admits that he is far from reaching agreement with the medical profession on the method of payment and until that difficulty can be overcome we will not even have the limited choice of doctor which this measure proposes.

That brings me to the method of financing the health services proposed in the Bill. The establishment of regional health boards will take away authority from the elected representatives in every country and in every region. The Minister says that 50 per cent of the members of the board must be nominated or elected by health authorities but the other 50 per cent are to be elected in some unspecified way by the medical profession with a number appointed by the Minister.

One thing which struck me as being extraordinary when I was reading the Second Schedule was that these health boards are not to have the authority to appoint their own chairman or vice-chairman. One would have thought that that was an elementary power that any self-respecting committee, council or authority would enjoy but it is not to be enjoyed by this board. The Minister is to appoint a chairman and vice-chairman. That is a considerable watering-down of the authority of these regional boards.

That being the case and seeing that the elected representatives of the various health authorities of country councils and country boroughs are not now being permitted to call the tune, they should not have to make the same contribution to the fiddler as heretofore. Considerable power is being taken away in the field of health from the country councils and public representatives while, at the same time, the charge of 50 per cent on the rates is being consolidated by this Bill.

I know that the Minister can make a greater contribution than 50 per cent to the health services but will he do that? At the present time, and under existing legislation, he can make a grant of more than 50 per cent to the health services but he does not do it.

This system of financing health to the extent of 50 per cent out of rates is fundamentally wrong. It is an unjust and an unfair way of raising money and the fact that the money is being raised in that way is detrimental to the operation of the health services. It is not necessary for me to go further than the Minister himself to find an argument to support that charge.

When the Minister was introducing the Estimate for his Department some short time ago, he dealt with this question and he stated that if the health services were not paid for out of the rates they would have to be paid for out of general taxation. The Minister said that the only argument in favour of shifting the charge from the rates to general taxation was that the latter was a fairer and more equitable way of raising money. Surely that is an unanswerable argument in favour of shifting the health charges from the rates to the general taxation and surely this Bill should do that? This Bill should be used as an instrument for doing that.

If this Bill means anything, the cost of health will go up and, at the same time, authority and power is being taken away from the elected representatives and handed over to the central authority. Surely those are excellent reasons at this time for changing the method of financing health. While discussion here on the rating system might be very tedious it would still be in order because it would show how unfair and unjust it is to continue to finance the health services to the extent of 50 per cent out of rates. The system of local taxation through rates on an artificial valuation has been in operation here since 1852 or thereabouts. It is based on what was known as Griffith's valuation which commenced in 1852 and ended in 1865. By the time that valuation was completed it was out of date because the valuation began immediately after the Famine and having regard to famine conditions and ended 13 years later when the effects of the famine had subsided.

That is the system of rating under which we are operating. That is the system of raising money under which the Minister proposes to raise 50 per cent of the health charges which will be payable under this Bill which is now going through. That is unfair and it cannot be justified. We know, and the Minister knows, that the system of levying rates has no regard to the capacity of the person to pay. You have two houses side by side in County Mayo, each with a valuation of £20. The occupant of one house may well be a well off person and the occupant of the other house may be a person finding it very hard to make ends meet. Under the present system and under the system proposed to raise money for health services in the future both persons would have to pay £100 in rates. That is unjust, immoral and inequitable.

Is it any wonder you have bodies like Dublin Corporation alienating themselves in an effort to publicise and bring home to the community in general how inequitable the present rating system is? In some parts of the world people burn themselves alive in order to draw attention to a grievance. Here you have Dublin Corporation and other bodies committing suicide in public, shall we say, in order to bring home to the Government and to the Minister the inequity and injustice of financing health services out of rates.

Does the Minister believe the system is fair? Does the Minister believe the system is just? Does the Minister stand over his speech on the occasion of the introduction of a Supplementary Estimate when he said the argument in favour of shifting the charges from the rates to the central Exchequer was that the latter was a fairer system of raising money? I assume the Minister does. If so, he should persuade the Government to accept the system whereby the health services would be financed out of general taxation until such time as a more equitable way still of financing the health services is introduced by the Fine Gael policy.

I have dealt already with the health boards. The health boards which are to be set up are to have certain powers. A chief executive officer is to be appointed. The first such officer will be appointed by the Minister but we have not been told what the necessary qualifications of this officer will be. Will they be administrative qualifications or will they be medical qualifications? I think the House is entitled to know what the qualifications will be.

Mostly administrative qualifications.

(Cavan): Many people are anxious about that point. I have dealt with my principal objections to the Bill which, as I say, are the means test, the inadequate choice of doctor and the outrageous method of financing it. There are a few other odds and ends I should like to deal with. One is the problem of mentally retarded children. I know the Minister thinks he is doing a good job in this respect but I must say I cannot agree with him. Until some impact has been made on this problem and until parents who want to have those children institutionalised can do so in a reasonable time without having to wait for several years, the problem is not being solved. Indeed, it is far from being solved.

The Minister should initiate a crash programme, a programme which would solve this within 12 months. Accommodation is not any problem. Deputy McLaughlin spoke today about a convent which is closing down in Sligo-Leitrim and this building could be used. This is something which must be tackled immediately. I am sure the Minister appreciates the problem but I would say that brakes are being put on him by the technical advisers of his Department and the Government saying you cannot rush into this. This is a problem which cannot wait.

That is total nonsense and the Deputy knows it, unless he thinks I am a liar.

(Cavan): I have not said the Minister is a liar. Will the Minister concede there is a waiting period of up to five years?

I do not say anything more than this. This has absolute priority in funds and the Deputy knows it. Will the Deputy tell me how to do this better than we are doing it?

(Cavan): I am only looking at results.

That is easy.

(Cavan): I come in contact with the parents of those children. I know what the problem is. Perhaps, I am giving something away in saying that the late Minister for Education got the very same sort of advice when he spoke about introducing free post primary education within 12 months.

What sort of advice?

(Cavan): That he was going too fast and that the teachers were not there.

Can the Deputy show me any method by which we can go faster with regard to mental handicap? Show me the medical care, the nuns, brothers and staff.

(Cavan): Has the Minister not the technical advisers?

It is not a technical matter.

(Cavan): There must be nursing staff available for these unfortunate children. There must be medical staff available also if the Minister and the Government were prepared to pay for it. It is only a matter of housing the unfortunate children in suitable buildings with some people to look after them. The Minister always gets a bit annoyed when this is mentioned because he feels he is doing his best but, as somebody said, his best is not good enough so long as there is a waiting period of up to five years.

I was interested in Deputy Andrew's contribution on the subject recently in this very debate when he advocated that until such time as it was possible to institutionalise these children, if they should be institutionalised, proper allowance should be made to their guardians or parents. The converse is the case. Supposing there is a retarded child and his parents are liable for income tax — and mind you, people with not very substantial salaries at the moment are liable for income tax— they get an allowance when that child is 11, 12, 14 or 15 years of age. They will qualify for an income tax allowance of £150 for him. When a child passes 16 years of age he ceases to be regarded as a child and becomes a dependent relative and the allowance drops to £60. That is something that is relevant on this matter. The parents of these children are entitled to some help until such time as proper provision can be made to accommodate them in institutions.

When dealing with the system of financing the health services I overlooked making one point. In the past the fact that these services were financed out of rates has acted to the detriment of the services. For example, under the present scheme a county council or health authority could provide free dentures. They had an alternative to provide them or not. Some counties failed to make that provision to provide free dentures because they found that the county could not afford it. They felt that the rates could not afford such a service. I know counties where people can get teeth extracted free of charge but cannot have them replaced at all because they have not got a scheme. That is because the scheme would have to be paid for out of the rates. This measure makes it obligatory on the health board to provide free dental, ophthalmic and aural treatment.

There are certain permissive provisions in this Bill. For example, the health board may provide home nursing care for elderly people. The health board may provide workshops for retarded people but the elected representatives on these health boards will bear in mind when considering this that this will be an addition to the rates. It will influence them in deciding to provide or not to provide it. That is another argument against the decision to continue to make rates liable for health charges.

I conclude by saying as I did when I began that this Bill simply is too late and contains too little. It is introduced several years after it was promised and three years after the White Paper. The White Paper is already out of date and the Bill does not even completely measure up to it.

With regard to the introduction of the Health Bill which I referred to within the past two months, I think it was Deputy Fitzpatrick who referred to the fact that it has come too late. It is ridiculous that years after we were promised a change in the health services we should still find ourselves having done practically nothing. I am convinced that this Bill for which we have waited so long has been rushed because of the particular year we are in. There are not many changes to my mind. There is one point I should like to refer to here—I mentioned this in the House before—and that is that there should be special arrangements to keep doctors in remote areas. We have found it difficult in our own county to get a doctor to take up a dispensary job temporarily for the simple reason that while we were awaiting the new health measure we had been informed that no permanent appointments were to be made. I suggested in the House before that some incentive should be given to such doctors in such cases in order to ensure that it would be possible to get them to remain in rural areas.

With regard to the medical services in general I just want to refer here to the explanatory memorandum. The question of eligibility is something under the health legislation which has caused a lot of confusion.

On many occasions people have come to me because they have been turned down for medical cards, the reason being, of course, that the aggregate income of the household had been taken into account. At least this Bill provides for an improvement because it requires only that the income of the husband and wife be taken into account. Members of the House will understand that there may be three or four members of a family in employment. The total amount of the younger people's earnings would not be more than £20 or £24 a week and everyone will appreciate that not much of this is handed over. It is therefore grossly unfair to take the whole income of the family into account.

It is most disappointing that the Bill does not seem to contain any hope of relief for the ratepayers. We on this side have been advocating the financing of the health services on an insurance basis. As I have mentioned already in the House, the demand on the ratepayers in my county in respect of health services is more than 30/- in the £ and this Bill does not hold out any hope of an easement for the ratepayers. Indeed, the contrary is the case because the prices of drugs and the cost of medical attention are not getting any cheaper. In my county the local contribution is something like 54 per cent. If the cost of medical services were borne even on a 50/50 basis, locally and centrally, there would be some hope for the ratepayers but from what one can understand from the Bill, this will not be so.

Having been a member of a council more than 20 years, I know that it has not been the line of the council or of any member to question in any way the cost of providing necessary medical care for people unable to provide it out of their own resources. As I have said, drugs and medicines are not getting cheaper and there is nothing in the Bill to help to meet the increases in cost otherwise than through the rates.

Another question arises here and, again, it is not the first time I have mentioned it in the House. It is the choice of doctor. The Bill provides it "where possible". That is a broad statement. I cannot see why a person unable to provide payment to a doctor should be confined to the dispensary doctor in his area when people who can afford to pay have a choice. This matter has not been spelled out sufficiently in the Bill. The Bill leaves much to be desired.

Deputy Fitzpatrick referred to mentally retarded children and the Minister asked him to put forward a suggestion and said that he would consider it. We all realise that there must be trained staffs in institutions for the care of such children. There seems to be something lacking here. In my constituency I know of families with one or more mentally retarded children who find it impossible, in a reasonable time, to get the children into institutions. I know of one case where there are three if not four mentally retarded children in the household, not one of whom could be got into an institution for the necessarily prolonged treatment. One of them was able to be institutionalised for a month during the summer but after this short period the child had to be returned to the parents. Though the Minister may be sincere when he says he regards this as a high priority, something must be done quickly to improve the situation. The important thing is to provide accommodation for those children at the right time. Many young boys and girls can get into institutions only after they have been waiting many years.

I wish now to refer to hospitals and their regionalisation. There is a county hospital in Kilkenny. We are not fortunate enough in Carlow to have a county hospital although, indeed, many thousands of pounds have been spent over the years on plans. At one stage we were told we would get a new hospital but that never materialised. There is an excellent county hospital in Kilkenny city which I understand will be downgraded under the regionalisation scheme. While there may be a lot to be said in favour of the large hospital with complete facilities and surgeons specialising in different branches of medicine, at the same time there is the difficulty that people will have to go to hospital a long way from home and their relatives may not be in a position to travel long distances to visit them. This is a hardship. We all know that when one is in hospital one likes to be visited by somebody from home. I feel that under this regionalisation scheme the distances between hospitals will be far greater than one would have expected. It is a pity to downgrade a hospital like Kilkenny, which is regarded as a first-class hospital, and perhaps, even to use it as an institution for old people.

I want to go back again to the question of medical cards. In our county, which is small, we have a high percentage of medical card holders. I know from my experience of making representations that medical cards are not given out lightly. One is told: "So and so has a medical card. I am worse off than he is and I cannot get one." We hear this every day of the week. My main objection to this Bill is that there is no improvement here except that only the income of the husband and wife will be taken into account. Even at present medical cards are given out to people whose means are above the limit where there are extenuating circumstances, for instance, if a person is on expensive drugs. The Minister does not seem to have done anything new here. He will recall that even in the last few months we in Carlow County Council adjourned our rates meeting on three or four occasions and I met the Minister to discuss with him the question of a greater allowance from his Department. Fifty-four per cent is the figure at the moment. He was unable at the time to do anything about the matter and the result was that eventually the council had to strike a rate of over 30/- in the £. There is nothing in this Bill to give us any hope that in future this will not increase and increase considerably. Naturally, every council wants to give this service to the people. Anybody who has any regard for people who are unable to provide out of their own means a medical service would not deprive them of this but we must remember that the burden of this does not fall only on ratepayers who are not in receipt of medical cards. Medical card holders themselves are also subscribing to the rates for the services which they are getting. How long can ratepayers in general and particularly the poorer sections of the community afford to meet these rising costs?

I am disappointed that there has not been a complete change of policy on this. I am not being critical of the Minister personally on this because I understand that all these things are discussed by the Government as a whole but I have a feeling that this Bill would not have been introduced if we were not faced in the near future with a general election. For that reason I think it has been a rushed job. Enough thought was not given to it. It was simply brought into this House in order that it could be said by the Government, when they have the responsibility of facing the electors, that they introduced a new Health Bill. There is practically nothing in the Bill. What is in it has come too late. I do not believe that the people will fall for what I might describe, if I may use the expression, as an election gimmick in bringing this Bill before Dáil Éireann practically on the eve of a general election.

I sympathise with any Minister for Health who is introducing a Health Bill because we must all admit that it is a pretty difficult job to satisfy everybody. In my honest and humble opinion the Bill introduced by the Minister falls short in many cases of satisfying most people. Even at this stage, perhaps, the Minister could see his way to amend it so that it will satisfy more people than it does now. Some of the details and suggestions in the Bill are vague in the extreme.

The first matter I should like to mention is the cardinal principle, the one which we were all looking forward to seeing, the principle of a free choice of doctor. This is mentioned in the Bill but I think the words "where possible" are added. This leaves an escape hatch which I do not like. I wonder did the Minister and his advisers go into this in detail to find out if this is necessary. If possible we should expunge these words from the Bill. I can imagine health authorities, when the regionalisation takes place, getting out of questions addressed to them because these words are in the Bill. I wonder could the Minister tell me if this is possible in his opinion.

We will be discussing this on Committee Stage and I will also refer to it in my speech. This is only a saver. Obviously there are certain areas where it will not be possible to provide a choice of doctor.

Is the Minister satisfied that there are some areas where this will not be possible?

I am. There are other aspects to which I will refer later. There are certain areas where for local reasons they may wish to postpone the application of the principle of choice of doctor for a short period.

I accept the Minister's undertaking that he has gone into this in detail and that, like me, he would prefer not to have those words in the Bill.

It is only right that I should refer to a problem which is agitating many people down in Cork. The Minister has agreed to meet the representatives of the Cork Health Authority with regard to the downgrading of Mallow Hospital. Apparently it is proposed to close down or downgrade this hospital. Can the Minister say does this Bill commit us to closing down or downgrading it?

We are not committed?

The Minister has an open mind on which hospitals will be closed down?

We have accepted the recommendation in principle only.

I should hate to think I was voting for the closing down of the hospital I mentioned last night.

A suggestion was thrown out that the Mallow County Hospital will be downgraded. The people of North East Cork are very perturbed about that suggestion. Mallow County Hospital has given excellent service. It has an excellent staff. It has been expertly run for many, many years. It is true to say that it is only 20 miles from Cork city, but the hospital serves the hinterland for 25 miles to Ballydesmond. The people in that area are most perturbed. Possibly it could be said that the people of Mallow might be served better by a regional hospital in Cork city, and the people of Mallow town are not worried to the same extent as the people in the 20 to 25 miles between Mallow town and the Cork and Kerry border to Rockchapel and Ballydesmond.

Since this suggestion was thrown out these people have held several meetings in Mallow and different places which I attended with other Deputies representing the area. They have a genuine case to make for the retention of the Mallow County Hospital as a unit which it now is. When the Minister and his officials come to a meeting in Mallow, in the near future I hope, we will have discussions around the table in a gentlemanly and orderly fashion, and I am quite sure that the case which will be presented by these people will be sympathetically received by the Minister and his advisers.

This is an era, unfortunately in my opinion, of takeovers. We have seen this in the supermarkets too. I have a personal objection to takeovers of one form or another. They are not good for the country and they are not good for the economy. They ensure that fewer of our people will find employment in their native land. Any move we make in that direction in business, economics or health should be carefully and diligently studied. I call this regionalisation a takeover.

This Bill suggests that fewer public representatives will have a say in the running of the health authorities and in expressing their views not only on the running of hospitals but on health matters generally. This is an undesirable approach. As a member of the Cork Health Authority I can say without fear of contradiction that all members of different Parties on that authority have made valuable contributions, and guided the manager and his officials in the running of the authority and the hospitals under its control.

I cannot see how the regionalisation of those boards will do anything to improve the situation. The elected representatives have to go before the people periodically for scrutiny and election. The electorate are most intelligent people and, by and large, their decisions work out for the good. If we in this new Health Bill decide to give less voice to those people who pay the piper, that is, the ratepayers, they will not be too happy about the change.

I presume that everybody who has spoken here on the Health Bill has referred to the health charges and it is well that they should. This problem will have to be tackled immediately and in a most deliberate way. I know that money must be found if we are to have an efficient health service, but the Minister, indeed, every member of the Fianna Fáil Party, will agree, that some other means of financing these services must be found. I have read about the meetings of the different local authorities throughout the country, and we have the example of the action taken by the Dublin Corporation, which is no longer functioning on this account. That in itself should indicate to the Minister and the Government the crying need for immediate attention to the problem of the health charges.

It is all very fine to say that it must be done some other way and the Minister would be eager to ask me what suggestions I have to make. I am not in a position to implement suggestions even if I made them, but the Minister and the Government must give serious thought to this. We had a situation in the urban council in Fermoy only last Monday night week where the rate on the people in that town was increased by 10s in the £. I remember a time, not many years ago, when I joined that authority first, when, if there was a proposal to increase the rate even by 1s or 1s 6d, there would be a stampede outside the council chamber. I am just wondering how long the people will remain patient. There are many protests all over the place about things that are much less near to the hearts of the people. I am making an appeal to the Minister that before this Bill is enacted a statement should be made that would give the people some hope and encouragement in facing the bills they have to meet in regard to health charges.

I believe the people would be prepared to pay for health services but not in the manner in which they are asked to do it now. There are many of them paying for services from which they get no benefit whatever. This is the injustice of the whole thing. All of us are delighted to help those who are not lucky enough or not affluent enough to pay for health services for themselves. We all realise the intolerable burden that can be placed even on reasonably well off families when sickness strikes them. Whatever may be said of us, we are regarded as a generous race and we help our fellow men and women in times of hardship through ill health. If it could only be made clear that the burden of health charges will be spread in a more equitable way, people would be better satisfied.

Deputy Governey said there was a problem in his county in regard to medical cards. This is a problem in every county and every health authority. No matter what system is devised here, as in many other areas of health legislation, there will be dissatisfaction. From my experience of different managers of the Cork Health Authority, I can say they were all most reasonable when a case was made to them. In fact, it is only fair to say that the managers and assistant managers of the Cork Health Authority did their utmost to help in this regard It is a pity we cannot do away with medical cards altogether. It does not matter whether it is called a blue card or a medical card, there is a stigma attached to it. I am not sure if this Bill proposes to retain that description of the thing that entitles a person to free dispensary services and free hospital treatment. I should like to see some other description substituted.

I am glad to note the Minister has now decided that it is only the income of the husband and the wife that will be taken into account in issuing medical cards. There are too many examples up to now of different health authorities taking into account the income of the son and the daughter who might be living at home but certainly would not be contributing anything to the family budget. Here at least some progress has been made. No matter what health legislation is introduced and no matter how complex and detailed it is, it will not give entire satisfaction, but this is one of the things in the Bill that strikes me as meeting the people in the right way. While we might be critical of some parts of this Health Bill, at least we give credit where credit is due.

Reference was made here to the problem of mentally retarded children. This is a question with which the Minister for Health must grapple in a more serious way than we are doing now. There is no greater affliction in any family than the introduction to it of a mentally retarded child. Unfortunately, in Cork, as elsewhere throughout the country, hope of these children being looked after is deferred for different reasons. I suggest that the Minister and his Department, irrespective of where the money comes from, because we are all ad idem in regard to this problem, must tackle the problem in a much more positive and serious way. The Minister must have statistics available to him showing the numbers who have been waiting for years to get into institutions for treatment. Waiting hinders their ultimate benefiting from treatment because they are deprived of treatment in the years in which it would give the best results, the years between three and six.

Debate adjourned.