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.