I am not absolutely certain whether amendment No. 36 was passed or not last night.
Health Bill, 1969: Committee Stage (Resumed).
Question proposed: "That section 36, as amended, stand part of the Bill".
Yes, amendment No. 36 has been agreed to.
Question put and agreed to.
SECTION 37.
I move amendment No. 41b:
Before subsection (3) to insert a new subsection as follows:—
"() For the purposes of the foregoing subsection ‘arrangements for providing services therein' shall be construed as referring to questions of time, place or eligibility, and not to the manner in which services are provided."
The section as it stands says:
(1) A health board may, with the consent of the Minister, provide and maintain any hospital, sanatorium, home, laboratory, clinic, health centre or similar premises required for the provision of services under the Health Acts, 1947 to 1969.
(2) The Minister may give to a health board such direction as he thinks fit in relation to the provision or maintenance of any premises provided and maintained under subsection (1) and in relation to the arrangements for providing services therein, and the health board shall comply with any such direction.
It is important that it should be made clear to everybody that this does not refer to certain things, such as the manner in which the services are provided. This amendment is put in to make sure that the arrangements for providing the services shall refer to the question of time, place or eligibility but not to the manner in which the services are provided. The Minister may say this is not likely to happen but it would be too bad if he could say to a section of the people that they could get a certain type of treatment and as the section stands he could say this. I should be glad if the Minister would comment on this matter. If he tells me he is prepared to alter the section to cover my point I am prepared to meet him on it.
This seems to be related to amendment 21a to section 16 and I have already dealt with it. This amendment would have the effect of preventing the Minister for Health from issuing directions on the manner in which services are to be provided in hospitals: it does not-relate to the manner in which the medical profession would carry out their duties or to the treatment they would give. Arrangements for providing services must cover more than questions of time, place and eligibility.
For example, the Minister must have some part, some power in relation to the methods used by hospitals for purchasing drugs and equipment and the general administration of hospitals —organisation of catering and so forth. He must be able to make use of what knowledge he has in the Department to see that these things are done before he can begin to promote modern methods in the best and most economical way. Obviously the Minister, who is ultimately responsible for the country's health services, must have some ultimate power to give directions in these matters.
It is fantastic to think that I would use this section so that I could direct doctors how to treat patients. I copper-fastened that in my comments on section 16, and the Deputy can be assured that this power would never be construed in that way. If the Minister for Health started to dictate to the medical profession, there would be such a flaming row——
History has proved to us that Ministers for Health in certain countries had rights written in many years ago to instruct doctors and surgeons how they should treat certain patients. When they were accused of overstepping their duties, these Ministers for Health were able to point to innocent looking Acts and say: "There is the power". I would be the last person to accuse the present Minister of anything like that, but we are here not making law for the present Minister for Health but for this land and it is law which will last for a long time.
For instance, the Minister has told us it will be 15 to 20 years before some sections of this Bill become operative. We can, therefore, assume that we are making law for 20 years or maybe longer. I fear that there is too much authority being given to the Minister by this section and I appeal to him to have another look at it. If, after further examination, he decides that nothing like this would be done, I am satisfied. If he is not so satisfied I ask him to have the necessary alteration to the section made before the Bill becomes law.
I am perfectly prepared to ask the officers of my Department to get in touch with the legal draftsman before the Bill comes to its Report Stage to see if there is anything in the Bill which would enable me to dictate the manner of treatment.
I accept that.
Amendment, by leave, withdrawn.
Question proposed: "That section 37 stand part of the Bill."
This section could be a useful one but it could also be one of the most dangerous in the Bill. It entitles the Minister for Health to give directions to any health board as to the manner in which services are to be provided and as to the number of hospitals, sanatoria, homes, laboratories, clinics, health centres and similar premises to be operated by a health board. Under this section, the Minister for Health may, if he thinks fit, order the closing of a hospital. He may order the closing of a number of hospitals irrespective of objections voiced by local doctors, by local nurses, by the community and by public representatives.
It is, therefore, a section which must be examined very carefully, and the view in Fine Gael is that this section is too wide, too dangerous, too extravagant in the use of power which it gives to the Minister for Health. We fear that full consideration will not be given by the Minister for Health to the interests of the patients and the personnel who operate the hospitals. We appreciate that this is based on recommendations in the report and outline of the future hospital system, referred to as the FitzGerald Report. Although that report has a number of sound basic arguments, it would be dangerous to overlook the desirability of giving full consideration to maintaining the excellence of the Irish hospital structure which has given it a personality, a humanity and warmth and a community interest and close relationship between patients, doctors and the community, that could not be found in other countries.
Some of the international recommendations in relation to hospitals have arisen because of problems which exist in other countries and which to date have not developed here, although I appreciate there is a danger some of them may. I have particularly in mind the problems which arise because of inadequate numbers of nurses and medical specialists. But the very problems which we are endeavouring to provide for in this section could possibly be accentuated by the methods which we are proposing to overcome or to prevent them.
If there is to be a substantial closure of local hospitals throughout rural Ireland, which in some cases are staffed by married nurses, we could easily arrive at a situation in which we would have large regional hospitals, large general hospitals, without having nurses available to those hospitals because of the distances which qualified nurses would have to travel to reach such hospitals.
This is something, therefore, which we must approach with considerable caution. In the giving of directions to health boards as to the hospitals which they must maintain or must close, there are no guidelines set out in the Bill, there are no signposts indicating the directions the Minister has in mind; and there is no obligation on the Minister to consider many of the problems which have been referred to in the course of the debate on this Bill. There is not even an obligation on him to consult with health boards before he gives directions.
The Minister will probably say that it would be unreal to think he would not consult with health boards. The practical probability is that the Minister would have such consultations, but there is no obligation on him to attach weight to any views which he may receive. Therefore, we must pay particular regard to the problems which will probably arise in some parts of rural Ireland where immense distances will have to be travelled on inadequate roads to bring patients to the hospitals if the suggestions in the FitzGerald Report are to be accepted in toto.
People in such counties as Donegal and Kerry, for instance, have some substantial distances to travel and yet the proposals which have been made would appear to indicate neither of those areas are to have general hospitals of their own. If a very modern, satisfactory, well-equipped ambulance service were guaranteed, then one could accept with more equanimity some of the recommendations proposed in the FitzGerald Report but we must insist that a condition precedent to the closing of any hospital would be the immediate availability of the very best ambulance equipment.
County Donegal, for instance, has a very unfortunate history in relation to ambulance services. The local authority's ambulance service was quite inadequate and because of this inadequacy it fell to the community by voluntary effort to provide a modern ambulance service. This has been used on innumerable occasions because of the non-availability of a local ambulance service or because of the delays which have arisen in providing an ambulance service. This is unsatisfactory and I think Donegal has proved its point. By voluntary effort an ambulance service was made available which the public authority had failed to provide. That was in a different hospital structure to that which is now proposed. Donegal is to lose one, if not two, of its hospitals and the public authority have not yet accepted the necessity for a substantial improvement in the ambulance service. It is only by the establishment of a national ambulance service, with the very best modern equipment and fully staffed, that we can face any possibility of the restructuring of our hospital services.
I sympathise with the Minister's remarks on the earlier amendment. I certainly interpreted subsection (2) which provides for arrangements for services as referring to catering, laundry and services of that kind rather than the application of medical skills, but I can see that the worries expressed by Deputies O'Connell and Tully could be justified if this were to be interpreted as applying to medical skills. There is a case to be made in urban areas for reorganisation of the services dealing with catering, laundry and so on, and we must welcome the streamlining of laundry services in the Dublin region. There is no justification for maintaining a separate laundry for each of the 57 hospitals in the Dublin area and our only regret about what has occurred is that it took the Department such a long time to come to the right decision and to take action to implement it. As a result of that, we had the ludicrous position of the Dublin Health Authority itself centralising its laundry services and undergoing a considerable amount of expense in order to bring about this centralisation. We now find that, having completed this particular restructuring, the Dublin Health Authority has received notice that it must close down this new central laundry and amalgamate it with a central laundry to be operated for both the local authority and voluntary hospitals.
If there is to be a centralising of health services, if the Department have any useful suggestions to make about the restructuring of the catering, laundry and ancillary services, then they must give their indications well in advance and prevent a recurrence of what happened in the Dublin region. What happened there was that the health authority for a long time wanted to get ahead with the centralising of the laundry services. It was prevented by the Department from doing that and the Department only gave their approval after a long waiting period, but a short time afterwards the whole idea was upset by having this new central laundry. However, this is all so much spilt milk and there is no use in crying about it but it is useful to point out now that this should not happen again.
We urge the Minister to give special attention to the provision of adequate living accommodation for nurses and to bear this in mind when he is considering the rearrangement of hospital and other services. Our nurses deserve a great deal more than they have yet received from our community and one of the greatest shames of our entire health services is the utterly inadequate living accommodation provided for them. Accommodation for nurses should be regarded as equally important as accommodation for anybody else. If you have not got a happy, contented and healthy nursing profession you are not going to have the best skills available for patients, and this matter must receive urgent attention in order to remedy the many defects which already exist.
This section, as drafted, is dangerous. Even with the best will in the world it is going to cause difficulty. It is going to lead to conflict and serious rivalry which will not be assisted by the lack of guidelines in the section itself. One can say where you have not got guidelines you have not got restrictions and, therefore, the section can be used with greater discretion according as circumstances may change. That is very well but, at the same time, we think it would be better to set out some principles which should guide the Minister in making his decision, and if in the course of time it were found necessary to modify those in the light of further medical developments and social requirements it would be open to the Minister to seek the approval of the House for any modifications that might be considered necessary. As it is now, we are writing a blank cheque for the Minister to close hospitals and clinics all over the place. While we appreciate he is not likely to do that without providing accommodation elsewhere, it is going to cause real trouble.
At the same time as the Minister is seeking this power we have not yet received from him or from the Government any indication of where he is going to get the extra money to build the extra accommodation to replace that which is going to be closed. The proposals in the FitzGerald Report, which are regarded as urgent, would require something in the region of £40 to £50 million for new hospital buildings in the next five years. This is something which has to be met and it is imperative that it be considered no less important than the provision of accommodation for university education. There is little use in having proposals such as those contained in the FitzGerald Report if we leave them suspended in the sky. It is vital that the Government accept and set out certain priorities and we believe one of those priorities should be the restructuring of hospital services and providing the necessary money. As the money must be provided, as the work must be done, as the principles in the FitzGerald Report are acceptable, we must not overlook the importance of maintaining adequate hospital services for all sections of the community, readily available to all.
One of the essentials must be the provision of an acute surgery unit in every county. We can understand why regional and general hospitals must be based upon a limited number of urban areas. That might be desirable or, indeed, necessary in order to have them adequately staffed and equipped within our budget but we believe it is equally necessary to maintain an acute surgical unit in each county because if you do not, many of the less complicated cases which are now adequately and expeditiously attended to in local hospitals will become serious or, perhaps, fatal cases because of the distances to be traversed.
The Minister's argument on this is that available evidence suggests that more people die or become chronically ill because of inadequate attention in local hospitals than would die or become chronically ill because of the long distances they would have to traverse to go to general or regional hospitals farther removed from their homes. But it will be of little consolation to the dying person or his next-of-kin to know that statistically he is insignificant and that statistically the argument was in favour of his dying and other people living. An effort must be made to maintain acute surgical facilities close to the people so that the appendix can be dealt with as efficiently in the future as in the past. The acceptance of that requirement does not over-rule the suggestion that we must also concentrate our efforts on building up modern, well-equipped regional and general hospitals.
Perhaps, I could shorten the debate on this section. Section 37 was drafted before the FitzGerald Report was published and before there was a great deal of discussion on it. First, you cannot close a hospital or institution without providing beds elsewhere for the patients concerned and the idea that a Minister for Health would order the closing of a hospital without providing beds or facilities elsewhere is impossible to conceive. Secondly, we are, of course, helping health authorities to improve the ambulance service through the ambulance committees, through provision of acceptable standards for new ambulances and by training of ambulance drivers. In that respect we have had a great deal of advice from abroad particularly from western and northern highlands in regard to the distances patients can travel in an ambulance to hospital.
The FitzGerald Report, with the exception of old and outdated hospitals in Dublin, did not recommend the closing of hospitals. It recommended change of function. In certain hospitals it recommended that surgery might end and be replaced by something which I regard as far more valuable, a complete diagnostic outpatient service with ambulance consultants who would help to keep people out of hospital. One of the objectives in our policy is to keep people out of hospital because we have too many people in hospital and staying too long in hospital. Our record for hospital stays is not too bad but it is not as good as in some European countries. We want to keep people out of hospital and treat them in advance for many conditions so that they do not have to go to hospital or will be there for a shorter period. The outpatient ambulance consultant diagnostic service is one of the most important features of the FitzGerald Report and is of far greater significance than anything related to where one conducts surgery of various kinds.
As regards the closing of a hospital I propose that we repeat the sections in the 1947 Act so as to provide a democratic procedure and provide that the Minister must hold a local inquiry before directing the closure of a hospital or institution. I hope that will satisfy the House.
The Minister will be putting down an amendment on the next Stage?
Yes, on Report Stage. Later on, I shall be explaining, in relation to the formation of Comhairle na nOspidéal, the proposals I shall have and the regulations will come before the House providing for a similar inquiry in the event of Comhairle na nOspidéal not recommending the appointment of some particular consultant in some particular hospital. That will arise on section 40. I hope that will satisfy the House. I believe in these democratic processes. I believe a Minister must finally act according to his conscience after hearing the result of an inquiry as to what he should do but that he should have the inquiry.
As the House may imagine it has taken me some time to grasp the main elements of our health services. I have been Minister only since July 2nd and I have steeped myself in this Bill. If I had the time to notice this obvious difference between the 1947 Act and this Bill, I think I would have said to my officers: "In modern times and with the need for greater communication and with more interest being shown by people in institutions we should have that inquiry arrangement put into the Bill". I am sorry I did not do it. I think it is perfectly reasonable to do it and I hope that satisfies the House.
A feature of the discussion on this Bill is that there are so many experts giving different views on it. Everybody who comments on the Bill claims to be an expert. I am not, let me hasten to add. I am an ordinary layman, a member of a local authority and, like the Minister and everybody else in the House and most people in the country, anxious to do the best possible for all health services. We should all accept that the people who drew up the Bill and advised on it, and the Minister, and both sides of the House agree that we should try to have the best possible service. It is necessary to say that because some people tend to say that one side or the other are attempting to knock down the improvements suggested.
On this section I should like to point out a number of things and first the fact that before the elections Deputy L'Estrange in this House asked the previous Minister, Deputy Flanagan, about a hospital in Mullingar. The reply he got was that it would be some time before a change would be made. Deputy Carter, who was sitting where Deputy Lenehan is now sitting commented: "Will it not be 15, 20 or 25 years before it will be possible to have the new hospitals which will be required to replace the existing ones?" Deputy Flanagan as Minister said, as far as I can recollect, in view of the money required and all the arrangements to be made, it could take that length of time.
It is necessary to remember that when we talk about certain arrangements having to be made under this section. Many people are under the impression that within five years we shall have a complete change in the hospital service but I think everybody now knows or should know, following the discussions here, that that is not so. Secondly, some of the suggestions made in the FitzGerald Report, which the Minister said was written after the Bill was drafted, are too ridiculous for words. For instance, there is the suggestion which would move a hospital patient across 60 miles over terribly bad roads to a central hospital which on the map might appear to be central but which would mean bringing him entirely away, not only from the place where he would normally get treatment but away from where there would be a bus service or access of any kind for relatives wishing to visit him. The Minister is as much aware as we are of the value of visits of relatives to people seriously ill. We seem to be at cross-purposes in regard to some of these suggestions in the Bill.
The Minister has made great play, and to an extent he is right, with the necessity to cut down the number of bed days in hospital if people could be treated as outpatients. I wonder does the Minister know what actually happens in regard to outpatients in most hospitals. These people are brought to hospital in one of three ways. They travel themselves if it is convenient, they travel by ambulance, or they travel by a local taxi employed for the purpose of bringing them to hospital. Usually more patients are brought to the hospital than can be dealt with in a reasonable time.
The first patient arrives at 9 o'clock in the morning and has to sit in a cold taxi, or minibus, or car, and it has been known for people, particularly people suffering from arthritis and ailments of that kind, to have to sit in a cold vehicle from 9 o'clock in the morning until 5 o'clock in the evening and, because of their condition, they cannot travel to get food. No food is provided in the local clinic. Will the Minister consider that when he is making arrangements for treating these people as outpatients? Will he remember that the present staffs are inadequate and that the present arrangements are completely outdated?
I was interested recently to hear in reply to a question that Kerry County Council had provided some food at their clinics—a mid-day meal or a hot meal of some kind for the patients who come in for outpatient treatment. The Minister must be aware that, in most cases, the best that can be offered is a vending machine offering coffee, which most people in the country do not drink anyway, or hot cocoa and usually the machine is out of order because somebody tried to get sixpence worth out of it for a washer. Let us be honest about this. There is no point in asking why do they not go down the town and go to a café or hotel.
Will the Minister try to explain to me how somebody who has a payment of less than £3 per week can go to a hotel and pay for a meal, even if he is able to get there? In many cases they cannot get there. This is too serious to allow it to pass by and say: "We will make a grand new world. All we have to do now is pass this Bill and we will have the patients who are not really ill, and who are being retained in hospital, treated as outpatients. They will be brought to the local clinics one or two days a week and there they will be cured in less time, and also have the comfort of their own homes."
The Minister must take an interest in this. It is not sufficient to say that somebody else will be doing it. This has gone on for far too long. At local authority level we have complained about it and the reply we usually get is: "The grant from the Department is not sufficient. The rates are too high. We cannot provide it"—and we are back where we started. That is one aspect.
The second aspect is the question of what the hospital buildings are likely to be. The Minister said no one will close the local hospitals, though they may change the actual arrangements. They will not be used for operations but something else will be done. That is all right up to a point but, if the hospitals are to be retained as the Minister says, what kind of staffing will be arranged? Who will staff them? The previous Minister gave a reply in this House which I interpreted as meaning that there might be a resident doctor in the hospital but that the responsibility would revert back to the doctor who had sent the patient in. How he or she could be responsible for looking after the patient if he was retained in the hospital for a while beats me.
They might be 60 miles away.
They could be 60 miles away. While most of the dispensary doctors, as we call them, are dedicated people, we know of the doctor who finds it extremely difficult to go 300 yards down the road to see a patient if he does not like him. I can see him going 50 or 60 miles to the hospital to see his patient once or twice a day!
Let us be practical about it. If we are to pass a Bill through this House which will govern the health services of this country for at least 20 or 25 years—if I may take the Minister's predecessor's word for it—let us have something on the record which will stand up in years to come so that people will not be saying in this House later on: "Were they not very ignorant when they passed this? They did not realise this was so."
I said at the start that all of us on all sides of the House are interested in improving the health services. We know all about the extra cost, and we know how hard it is to raise the money. One thing which I detest is having something written down painted in glowing colours giving people the impression that they will get something which they will not get. That is a big disappointment to people who really need treatment. Passing section 37, even with the suggestion that the Minister will have another look at one subsection, will not solve very much of this problem.
We must remember also that, apart from what Deputy Ryan has said about accommodation for the nursing staffs, there is another section of what I term nursing staff but whose title has changed from servants to non-nursing personnel. If we looked at the accommodation some of these people have we would get a big shock. Not so long ago, as a trade union official, I was asked to make representations to have certain accommodation provided for some of my members in an up-to-date hospital down the country, not in Meath. I was amazed to find that there were 30 girls sleeping in 24 single beds. One of the beds was so bad—luckily they had been playing camogie—that they had to use some camogie sticks to keep the mattress off the floor—this in 1969. There was one bathroom and toilet available to all those girls, plus the day-girls who came in.
I was told what it would cost to make an improvement. I was told how hard it would be to provide something extra. I was told the money was not there. It was not until I discovered there were a number of other bathrooms available in the hospital which was pretty close to them, which were not being over-used, shall I say, to put it mildly, and succeeded in getting the use of one of them for those girls, that it leaked through that the old idea of having two different races employed in hospitals was breaking out again. I cannot speak too strongly on this.
Those who work in hospitals are dedicated people whether they are doctors or nurses who have taken out degrees and trained for years or whether they are what is now known as non-nursing personnel, wardsmaids, and wardsmen. These people work in hospitals where old people are in bed and they provide bedbaths for patients and, remember, they are non-nursing personnel. The sooner one standard is applied the better for everyone.
There is one other section about which I have a question down for next week. Perhaps, I could give the Minister advance notice of it now because it also comes under this section. The question refers to what is to happen in regard to trainee nurses. I do not want to go outside the section but I want to tell the Minister that in this city there are some trainee nurses who are very little better than slaves. The accommodation offered to them is not what it should be—let me put it that way. I cannot refer in detail to hours of work, wages and food, but all these things will have to be provided for under section 37. Certainly, the accommodation which is provided and the type of food they get and the way it is cooked will have to be included. I hope the Minister will be answering my question next week and I would ask him to be pretty sure of the facts, particularly with regard to voluntary hospitals.
I know the Minister is deeply concerned to have this Health Act as near perfect as it possibly can be, but I would suggest when he found that certain things appeared to have been overlooked, that it would have been better to have withdrawn the whole thing and to have had another look at it with a fresh mind—I know the Minister has a fine mind for these things— and introduce a Bill about which all of us could be proud to say in years to come that we were responsible for putting on the Statute Book. There are grave dangers that the Bill before the House is not like that.
This is an enabling Bill. To put it cynically a Minister can commit any number of follies or good deeds under section 37. I agree with Deputy Tully that there are still grave defects in our hospital system. We have a great many improvements to make. County homes are being replaced or improved one by one; changes have to be made in mental hospitals; and the question of nursing accommodation in certain areas has to be tackled. We have made improvements but there is still a great deal to be done.
In regard to the FitzGerald Report this Bill does not in any way proclaim a particular decision by the Minister or by this House on the implementation of some of the proposals in that report. As Deputy Tully has said, it will take years and years before many of the decisions can be implemented because of the capital cost and because of the need to make further studies.
I have not given a time by which all the decisions of the FitzGerald Report should be made. I have been studying the report and I have been talking to people about it and within the next 12 months to two years I want to try to get an approximate time basis in relation to capital cost and to see what the cost would be if all the report was implemented, even though there is no obligation on me to implement it. Obviously, the report needs study and, no doubt, there will be amendments and changes to it. It is not a sacrosanct report. The report has been repeated in reports in Denmark and in Scotland. Only the other day we had published by the Department of Health and Social Security of the Welsh Office, Central Health Service Council, a book entitled, "The Functions of the District General Hospital", which makes the same sort of observations. The amendment I have suggested provides for an inquiry if an institution is actually to close.
In connection with the formation of Comhairle na nOspidéal in making the recommendations which enable this body to decide on the appointment of consultants throughout the country, the regulations will have to include proposals or observations by the local county health committee before Comhairle na nOspidéal can make a decision to change the functions of consultants in a particular area. Indeed, so far as that is concerned the Minister has the ultimate power in all these matters.
Having said that, I do hope the House will help me to proceed with this Bill. I could come in here briefed for at least a two hours' speech on all the implications of section 37, in regard to the various changes of hospital administration. I could comment on certain inadequacies in the FitzGerald Report, not caused deliberately, but caused simply because it was a report prepared by people who did their best to examine the whole hospital situation in the country. They could not possibly have known all the factors surrounding the hospitals in different places. I could give a list of all the places where nurses' accommodation is being provided and I could discuss the quite evident lack of nursing accommodation in other places. I could go through all the mentally handicapped institutions indicating the number of places that would be reserved in the next two years for mentally handicapped children, about whom I have a very intense and sympathetic feeling; and I could indicate the deficiencies in the child health services. All these things arise on section 37 and the reason why I have not come briefed in that way is that we would never get the Bill through if we were to do that. However, I would be interested to hear Deputies' views on their interpretation of section 37 in order that I could reply to them on a great many local matters. We could have a long debate on the improvements and deficiencies in the hospital services, rather like the debate on the Health Estimate, but we have recently had two debates on Second Reading of the Health Bill and also on the resolutions put forward by the Fine Gael Party on health services and because of this I have not come briefed.
As I have said, you can give the widest interpretation to this Bill. I guarantee an inquiry before the closing of a hospital or an institution and I do hope the House will bear with me in regard to this. I have already said on several occasions that we are going to put into a regulation to Comhairle na nOspidéal a statutory provision that the local health committee will be consulted before any action is taken by Comhairle na nOspidéal.
The existing one or the new one?
The new one.
The new committee may not be representative of the area at all. I am sure the Minister appreciates the fact that a county which has a health committee will only have two representatives on the new committee. Naturally, those in the area where the new hospitals are set up will be prejudiced.
This is the county health advisory committee, the one with so many county councillors from each electoral area and they would form a representative committee of all health interests.
This is a very wide section dealing with hospitals all over the country, but I am only concerned with the problems of the people who sent me here. I appeal to the Minister not to close Roscommon County Hospital but to upgrade it instead. The Minister's colleague, the Minister for Transport and Power, promised the people of Roscommon that this hospital would be upgraded before the general election.
I think it is dangerous and unfair to expect emergency patients to have to travel anything up to 100 miles to a hospital. The Minister has spoken about good ambulance services, but I do not think they are good enough to get a patient to hospital in time. In the West of Ireland we have very bad telephone services and our roads are not the best. I do not know what will happen with regard to the weather conditions but they are a very important consideration when operating these services. I can see many deaths occurring. It will be far too late to do anything about it when lives are lost.
The Bill does not require me to close the surgical facilities in Roscommon County Hospital. If the Minister is inactive, when the Bill is passed, nothing need happen. As the House well knows, this is an enabling Bill which gives the Minister powers to do certain things. I cannot close Roscommon County Hospital as soon as the Bill has passed through the Dáil and Seanad and has been signed by the President.
This is a very important section. It is a very wide section in that it interests everyone in all parts of the country. I should like to direct the Minister's attention to the fact that a totally different set of circumstances exist in the built-up areas in the bigger centres, than in rural Ireland. Therefore, it is necessary that each and every one of us in this Dáil should contribute in so far as we can our views in relation to the future hospitalisation of the country. The Minister has just replied to Deputy Mrs. Burke that the passing of this Bill does not necessarily imply the closing of Roscommon Hospital. This is an enabling Bill and it is possible not only that Roscommon Hospital would be closed but many other hospitals as well. The legislation will give power to the Minister to do so.
That could be done under previous legislation, under the 1947 Act. There is no change.
I quite agree that Ministers could do it and I am not suggesting for a moment that the Minister is waiting for the Bill to be passed to close down hospitals wholesale. I am simply stating that the Bill will enable the Minister for Health to close hospitals. That is why those of us who represent rural constituencies whether in the west of Ireland or anywhere else are gravely concerned about this.
The Minister has further met us by saying he will have a local inquiry prior to taking any drastic action in relation to a hospital in any particular county. We are deeply appreciative of the offer the Minister has made to the House, but that does not mean we should close down on this debate and say: "Let us pass the Bill and everything will be grand afterwards." We must fully state the pros and cons in relation to hospitalisation. The most important thing in this section is the overall hospital plan. Many of us who have discussed this matter among ourselves, with our constituents, with people on local authorities and others who are particularly interested are not very happy with the overall hospitalisation plan. Anyone with any medical understanding of the situation will naturally agree that you must have bigger centre hospitals to deal with definite specialities which are not within the compass of an ordinary general surgeon or general physician even though he may be of consultant standard. But that does not mean ipso facto that you should do away with the functions of the existing consultant staffs that exist in certain areas. It can be done but it is not in the interest of the public or the patients to do it. Serious harm and injustice would be done to the public at large.
I have not announced a plan.
I am not accusing the Minister of being unreasonable. I admit he is a reasonable and honest man and I know he has given a great deal of study to this. He said a few moments ago that he was prepared to be fully briefed, if necessary, to speak for two hours in answering us. Surely it is up to us as the representatives of public opinion— we have just gone through the mill to prove that; it is not so long since we were elected here—to place before the Minister all the facts as we see them. When the Minister comes in here to reply to us fully briefed, by whom will he be briefed? He will be briefed as far as the governmental side is concerned by the officials of the Custom House who are experts on matters of health administration and that kind of thing, but they are not necessarily fully conversant with the facts, and that is what we are here for, to make the facts known.
I may have made a wrong interpretation of this plan in relation to bigger regional centres whereby we are to have consultant staffs, experts, to deal with certain matters. For instance, an operation for the removal of a brain tumour would be far beyond the competence of the general surgeon; the complete removal of a lung would also be beyond the competence of the general surgeon. It is only natural that operations such as those would be conducted in highly specialised centres. Heretofore such cases went to Dublin and Cork, mainly to Dublin, and instead of these cases going to Dublin, there will be more up-to-date regional hospital centres to which they will be sent. I am not against that. I am sure any medical colleague of mine in this House will agree with me that it is necessary to have this absolute specialisation, but that does not mean that for the sake of economy—and very false economy it would be—that we must eliminate the existing operating centres in the different counties of Ireland.
What Deputy Tully said just now is perfectly true, that a patient may have to go 60 miles to one of these regional centres. One does not need any medical knowledge to know that if a person is bleeding it would be dangerous to send him 60 miles in an ambulance even though there is an emergency squad and there are up-to-date facilities in that ambulance. Travelling that distance, possibly over a pretty bumpy road, will increase the haemorrhage and increase the risk to the life of the patient.
One of the most frequent reasons for operations is the acute surgical emergency. Apart from the fact that, in my opinion, it is not right to send these patients 60 or 100 miles, it will be very expensive to do so. Secondly, it is entirely unreasonable to the relatives concerned. When a patient is sent into hospital we all know the anxiety of the relatives. They will get up at an early hour the following morning and phone to find out how the patient is getting on. The Minister was once the Minister for Posts and Telegraphs, and must know it is very difficult to get on to a hospital, which leads to further anxiety on the part of the relatives. Another problem is that of visiting patients. People like to visit their next-of-kin. Take the case that was just cited by Deputy Mrs. Burke in regard to the Roscommon Hospital. Under the scheme the people of Roscommon will have to go to Galway. How are people who live in County Roscommon to visit people in Galway?
I think every one of us should make some reference to his own constituency. We have formed innumerable committees in Wexford in connection with health matters. An organisation has been formed of which the Bishop of Ferns is the president; it is called the Save the Hospital Committee. It was formed because we believe what we have heard, that the surgical facilities that were to be available in Wexford will not be available. In Wexford we have been waiting for over 20 years for a new hospital to be built. We had got to the stage where the patients were moved out of the general hospital into another place to enable the new hospital to be built. We are now told the hospital will not be built, and the assumption is that we shall not have the surgical facilities we expected.
I accept the desirability of having up-to-date specialist hospitals for certain conditions that ordinary general surgeons and general physicians, even of consultant standard, are not able to deal with. If our hospital is closed— and the indications and suggestions in the FitzGerald Report are that it should be closed—our people will have to be sent to Waterford. County Wexford is in the province of Leinster and our patients will be sent to Munster to be operated on but, apart from that, they will be sent a considerable distance. The people who live in the north of Wexford will be sent further than the distance from Dublin to be operated on.
No decision has been made on this.
I know that no decision has been made and I am not accusing the Minister of closing the Wexford hospital. I am stating the case which I hope every Deputy will state from his own point of view to enable the Minister to state his position.
If every Deputy states it, this Bill will not be able to go through by 1971. It is quite simple.
Come, come —unless Deputies are going to speak for two or three hours. I shall not detain the House much longer. Having stated the general position, I simply want to state the position of those who sent me here from Wexford. The road from Wexford to Waterford is frequently liable to fog. That is another hazard in sending a case such a great distance. As the Minister grows impatient, I will conclude by making this suggestion to the Minister and to those who advise him: certainly, go ahead with specialisation; certainly have hospitals outside the city of Dublin provided you can get adequate staffs; certainly have specialisation outside the scope of the ordinary general consultant surgeons, physicians and gynaecologists but do not do away with facilities for acute surgical emergencies within county boundaries. If the Minister does away with these facilities he or some future Minister will be back in this House with a Bill to create the situation which I believe is necessary for the carrying out of acute surgical emergencies within the confines of a county. That is an opinion that is held by the greater number of rural Deputies.
I cannot let this section pass without some comment because I accept that this is the section that will eventually implement the FitzGerald Report. Naturally enough, each Deputy has his eye focussed on his own local situation. We in Roscommon find ourselves in a difficult one which has three contents: first, a political content which, for quite a while, has been the most difficult one because it was one of the issues in the general election and in the referendum and we had to deal with that and, in fairness to the people, we dealt with it adequately and the results of the election show that. It still continues to be a political problem within the county. This is unfortunate because this adds a second aspect to the emotional side of it which becomes both political and emotional. Emotion in discussions in local papers has become highly charged. The people are very conscious of the fact that they may be losing surgical facilities in their hospitals.
This brings me to the third point which is the vitally important point— the medical services which will be available to the people of the country following the decision of the Minister on this question. It is only fair to say that the county of Roscommon finds itself in a most unusual position because it has had a high standard of surgery there from the early 30s. The present surgeon has been there for some 30 years and he was preceded by a man who happens to be a Member of this House, Deputy Hogan, who sits on the Fine Gael benches, and whose services were very highly regarded within the county. So that the people feel that over this length of time they had acute surgical facilities comparable to those available in any part of the country and it was only in latter years, when the specialities and the specialists arrived, that there has been diversion of the surgical work out of the county hospital.
Unfortunately, the FitzGerald Report came out at a rotten bad time for everybody concerned, not only for the politicians but for the unfortunate people who had to make decisions on it. This was at the time of the referendum and the time of the general election and, in fact, we never got down to absolute basic thinking on the problem. It is very difficult to do basic thinking on it because this is based on statistics which have come from medical groups not alone in Ireland but in Britain, America and other places throughout the world. Personally, I find medical statistics very difficult to understand and at times I find it very difficult to draw conclusions from them or to understand the conclusions drawn from them. However, there is one aspect of this that I should like to have cleared up.
Deputy Esmonde said that the Department will be advising the Minister and that they will advise him in a certain direction. I am absolutely confident that whatever figures are available to the Department will be made available to anybody who wants them. I would not entertain the thought for one moment that they would advise the Minister in some way that would be to the detriment of the health of the people not alone of my constituency but of any other constituency. I have no doubt that other people examining those figures would disagree with them, unless they are very compelling altogether. I have complete confidence that if the Minister thinks he has to make a decision he will make it as he believes to be right. This is what troubles me—that in a very important matter like this it is very difficult to convince people because conclusions were reached by a committee who never visited our hospitals and it is alleged—I do not know how true this is—that they were unaware that there was a fully qualified anaesthetist in the hospital. This, again, is coming back to this much paraded question of failure and lack of communications.
In the last week it has been drawn to my attention that there was a seminar of some kind on regionalism—in Waterford I think it was—and one man—I do not know whom he represents—I suppose it is a British health authority or a Scottish health authority —spoke there. Unfortunately, I have not the original document. I have only the comment on it from one of the daily newspapers. He remarked on the fact that in Scotland before they changed their health services they went around and consulted with everybody —the people, the doctors, the nurses and everybody else. This must have some lesson for us.
Going back again to the general election, our local newspaper challenged all the candidates as to their attitude to county hospitals. I put mine in print. It was to the effect that the committee said this policy would not be implemented until 1980; 1980 is a long time away yet. I said that conditions would have changed so much in my constituency by then that all the circumstances would have to be re-examined before any decision could be made. The Minister's predecessor gave assurances to a deputation from Roscommon County Council that no decision would be taken without consulting the county council. The Minister restated that this morning; he said he would meet the future committee appointed. He also stated that to me and to others on one occasion. I accept that the Minister will do what he says.
My concern is that people should be convinced. The other aspect is the problem of acute surgery. I call acute surgery acute haemorrhagic complaints, acute appendicitis, appendicitis with perforation, ordinary perforation and strangulated hernia. These are five that strike me offhand. These are the cases in which the patients come back to the doctor afterwards and thank him for getting the patients into hospital in time and they are very pleased the surgeon got out of his bed and operated. Of course, if the doctor is missing for two or three hours, it is just too bad for the doctor; it may also be bad for the patient. There is this time element. From a medical point of view there may not be any absolute urgency but, from the point of view of relatives and patients, the urgency is immediate. Now the Minister and his Department will have to get it across to the people that time is not important. It is, of course, the duty of the Department to go into all these problems before they advise the Minister and it is their duty to be absolutely certain that their advice is sound.
Most of the statistics in medical journals seem to be based on concentrated populations in London, Manchester, Birmingham and cities throughout the United States. Such statistics have no application to Ireland. The Canadian figures have some relevancy. I should like to have the figures from northern Norway, northern Sweden and northern Finland. If these can show that the people will lose nothing, then this approach is correct. I confess I am somewhat confused. There seems to be this political content all the time, plus a highly emotional content, and we do not seem to be able to get down to the most important content of all, the medical content. I shall not repeat what has been said about relatives having to travel long distances and so on but so long as the matter is fully considered and the Minister comes back to the county committee again adequately advised I will have no argument against the proposal. I have no doubt that whatever advice is offered will be considered genuine advice, but I am more than anxious that he should have absolutely full advice.
I should like to say how much we appreciate the Minister's offer to amend the section on Report Stage in order to provide for a local inquiry in the event of a proposal to close a local hospital. That will ensure that local views will be clearly understood before any decision is taken. I say that with some reservation: my experience of local inquiries is such as not to give me much confidence in such inquiries. Local inquiries seldom if ever bring about a reversal of intent. Not infrequently a local inquiry is little more than window-dressing designed to give the appearance of democratic processes. It is, I suppose, a matter for the local people to appreciate that they must make their case, and make it well, before they can hope to convince the powers-that-be that some proposal is not to their advantage. I am not concerned with local pride or local prestige. That is a matter of no consolation to sick people or their relatives.
It is important that this Dáil should emphasise the importance of the small, voluntary, local hospital. Many of these were established as charitable foundations and they have something which general and regional hospitals do not have and will never have. They are run by committees of civic-minded people who give their time, their energy, their money and their expertise, far beyond the call of duty, to the successful running of these institutions. Religious orders and lay people have dedicated their lives, quite indifferent to financial reward, to looking after the sick, the infirm and the aged. Ministerial directions and organisations and methods will never replace the kindness, the understanding and the sympathy which is natural to a small community-involved hospital but which is a stranger to the large modern monster. This personal involvement, this intimacy, is many times more vital to the recovery of a patient than the best medical skills or modern drugs. If we depart too far from this purely social aspect we may end up like the Scandinavian countries with the large wards manned by television cameras and other monitoring systems, scanning patients in their beds, patients who are seldom visited by nurses, by the kindly people to whom the sick always look forward for the touch of a human hand in time of pain and suffering. We must be on our guard against this or we will create a monster which will generate new social and psychological problems.
We should all join with the Minister in his aim to cut down the number of days spent in hospital. There has been a substantial improvement, but we are all aware of the numbers of people who go into hospital for what are called "tests". This is the modern practice. People are hospitalised for the purpose of making tests. It is not uncommon for people to be required to enter hospital two or three days before the hospital is in a position to make the tests.
Parkinson's Law operates with constant and never-failing rapidity where there is a hospital bed. A hospital bed abhors a vacuum and a hospital bed without a patient is something that is very rare. It is something which, apparently, is abhorrent to hospital administration because a bed without a patient is a loss of income while a bed with a patient in it means income. It is because of that that we have this very high rate of hospital bed occupancy in Ireland. We are the most hospitalised nation in the world and I say that because all the recorded figures from the known countries indicate that we have more people in hospital beds than any other nation. The less-developed nations have not half enough hospital beds while we have far more than any other country of comparable social and medical standards.
That is something of which we ought to be proud but it is also something which should give us food for thought. We do not want a situation as they have in other countries where people are pushed out of hospital long before they should be. That is something we must guard against but, at the same time, we ought to try to orientate our health services so that they are socially involved and so that all the great improvements that social medicine can bring to bear on health problems are made available.
If that is done we will keep many people out of hospital beds who should never be there, many people who could be better cared for at home, many people who would not develop psychological and other problems if they are kept at home, and many people who by being at home can be involved in their own family and their family in them so that we would have a much healthier community.
I ask that in using this section the Minister would give particular attention to the overhauling of out-patient departments of hospitals. From what the Minister has said I know he is concerned to improve substantially the diagnostic services and the outdoor hospital services. There is a crying need for a radical overhaul of our out-patient departments. The experience which many mortals have to undergo in waiting three, four or, perhaps, five hours for attention in out-patient departments is appalling. Our efforts should be concentrated, if our resources are limited, on the improvements of the out-patient departments of hospitals so that we can get away from this business of requiring sick and injured and invalided people to wait for hours in hospitals. The pain and boredom of being forced to wait and waiting without the appalling cup of appalling coffee that Deputy Tully referred to is bad enough but it also creates very serious family problems because children and other members of the family are upset and this in turn upsets the invalided or sick person. It is something that we should try to avoid. I ask the Minister to give his attention to this matter.
The Minister mentions that he will have a local inquiry before closing a hospital but I notice that section 37 does not require the Minister to consult the regional hospital board before he gives any direction. However, I suppose it is unlikely that the Minister would proceed to issue directions for the closing of a hospital without having available to him the advice of the regional hospital board but this is not mentioned in section 37. Perhaps, as the Minister will provide for the local inquiry he might also consider having provisions for consultations with the regional hospital board.
Like Deputy Gibbons and Deputy Esmonde, I have experience of GP practice in the country. I welcome the new proposal to have highly specialised hospitals. It is a wonderful thing that we can have treatment of the highest type in Ireland but it is the distances about which I am worried.
In my constituency of Clare-South Galway I have been called down through the years to frightening cases in the middle of the night such as those cited by Deputy Dr. Gibbons. I remember on one occasion being called during the night to a man who was believed to have died. He had a perforated ulcer and I got a message to the effect that the man had vomited a lot of blood. When I arrived at his home I found that his pulse was imperceptible. He had been anointed but he was alive. We would have had to wait too long for an ambulance to get him to hospital. I suggested bringing him saying to his wife that he would probably die on the way. His brother and the priest and I carried the man to the back of my car and rushed him to hospital. The houseman there immediately put up a drip which I helped with myself and the surgeon operated. Thank God, that man lived and is an active farmer today but that is just one of the many cases which I have experienced. If we only had hospitalisation in, say, Cork, Galway or Dublin that man would have died There are often cases of women suffering bad haemorrhages during the night.
I mention that case to emphasise that we must have services locally and even improved services to cater for those urgent emergency cases. Afterwards, if it is necessary, they can be transferred to specialised hospitals for specialised treatment. That is the opposite to what was suggested by Professor FitzGerald on a television programme when he said that we should send the patients to the specialised hospitals and after they had been treated take them back to our rest homes or hospitals down the country. It is the urgency that I am worried about.
We have a fine hospital, Portiuncula, in East Galway. This hospital serves a large portion of Galway, North Tipperary and over to Athlone. A wonderful service is provided by this hospital and they have an excellent nursing school. I would much regret any reduction of services at Portiuncula. There is also a wonderful county hospital in Ennis. There is an excellent county surgeon there about whom I could not speak highly enough. I do not wish to say anything further on this section except that I would be very cautious in recommending the reduction of services in rural areas.
I agree with Deputy Esmonde that county hospitals should be kept. The service being provided by county hospitals to local people is much too important to be discontinued. I agree that specialisation is a wonderful thing, but if we could have specialisation in rural areas rather than in Dublin alone it would not be necessary for so many patients to be sent to Dublin and other places for hospital treatment. This would be possible if county hospitals were expanded and the surgeons, physicians and adequate facilities made available in these hospitals.
Over the years, a large number of patients have been sent for treatment in Dublin whereas they could adequately be treated in the local hospital if we had the staff to do it. We cannot expect one man to do the work of two men. This is what we are expecting of our county hospitals at present. Our hospital in Kilkenny is being extended and lately a gynaecologist has been appointed. If it were extended even further it would be of great advantage to people locally. This aspect should urgently be attended to. The big problem is lack of knowledge of what is to take place. The Minister said this morning that he has no plan. On the other hand, there are people who consider that the FitzGerald Report is the basis for future hospitalization in this country. It would ease the minds of a lot of people if the Minister would make a statement on his intentions and also on the FitzGerald Report.
In our local authority the fear is that our hospital, which is first-class, will be downgraded to become a rest home, a centre for geriatric treatment. It would allay a lot of the fears of local people and of the local authority if the Minister would state that the surgical treatment at present provided there will continue. Some people say that politics enter into the matter. My belief is that it is too important for politics. Certainly, the people in my area are at one in their view that our hospital in Kilkenny should not be downgraded and the services at present provided there taken from it.
Kilkenny is the centre of the south-eastern region. Yet, for some reason or other, the FitzGerald Report recommends that the regional hospital be situated in Waterford, a place which is on the coast. Perhaps this is the only political angle which attaches to the whole problem in the south-eastern region. Kilkenny was chosen as the site for an orthopaedic hospital because of its situation in the centre of the south-eastern region. To follow that thinking to its logical conclusion, Kilkenny should also be the centre for the new regional hospital. We have the most suitable hospital in the area for expansion: I do not think the Waterford hospital is suitable in this respect. If they want to site a regional hospital in Waterford they will have to erect a new building there for the job.
Does the Minister intend to leave existing hospital services in country districts which the local people consider necessary in their areas or does he intend to downgrade these hospitals? If people had some knowledge that the Minister intended that existing hospital services should remain, it would allay their fears and I do not think he would have much difficulty, then, with the regional aspect of his proposals.
The contributions to the debate by the medical Deputies have been very interesting. I would wish, too, that the Minister could assure— as I feel he can—the people in rural areas that their position will in no way be worsened by the proposals in this Bill. This is the age of specialisation. We need to have as many as possible under the one roof so as to avoid sending people from one hospital or building to another.
The word "downgraded" is the most unfortunate word ever used in this context. I believe that "down-graded", as understood by the general public, is not what is intended here. I should imagine that hospitals will continue to be used as they are now but that, as time goes on, a greater number of people will by-pass them and come to Dublin for specialist treatment. That is happening even at present. I would wish that the Minister could give the assurance that the position of the rural population and emergency cases will in no way be worsened and that the facilities at present provided in local hospitals will be available as long as we can foresee into the future. The time may come when there will be no delay involved in taking patients to specialist hospitals. I should be glad if the Minister would assure the House that until such time, there will be no worsening of the position of patients who need immediate and specialist attention.
There is considerable concern in County Meath about the implications of the FitzGerald Report as regards the future of Navan Hospital, an excellent hospital of its kind. It is generally recognised that the surgery carried out in Navan Hospital is almost unequalled in other parts of the country. The nursing facilities there are also of a very high standard. The health authority have never in any way been cost-conscious in regard to the hospitals or in regard to the services in general. Nothing but the best has been afforded to the people of Meath in Navan Hospital and it is understandable, therefore, that they should be concerned that the FitzGerald Report would involve the downgrading of their hospital to the status of a rest centre. They are particularly concerned in view of the fact that Navan Hospital is very well situated. The roads leading into Navan are very fast and well maintained. Therefore, people can reach the hospital very quickly. I am afraid that if the facilities which are at present available in Navan were moved to Cavan or Monaghan people from south Meath, and indeed from most of Meath, would find it much more difficult to get to the new centre than they do to get to Navan. This is not only because of the distance but because of the accessibility of Navan Hospital.
I want to echo the concern of other Deputies about certain types of cases which require speedier treatment than others and which would perhaps be endangered by their having to travel the extra distance to Cavan or Monaghan. Strangulated hernia, perforated appendix, accident cases and haemorrhage cases, have been mentioned in this regard. I sincerely hope that the Minister will be able to allay the fears of many people concerning cases such as these in relation to the FitzGerald Report. I know of an accident case which occurred relatively near to Navan. The person in question was able to go and get treatment in the orthopaedic unit in Navan. I am reliably assured that if this patient had had to travel to Cavan or Monaghan she would not be alive today. I would also be interested to hear the Minister's remarks on the future of this orthopaedic unit which is situated in Navan. This is a regional orthopaedic unit. Will the FitzGerald Report proposals involve the closure of this orthopaedic unit and its move to Cavan or Monaghan? I sincerely hope not. This unit is of a very high standard indeed.
There is another matter I should like to refer to. The doctors and medical people in Navan Hospital have been able with great effect to make use of consultancy services from Dublin and to have close liaison with the highly specialised facilities in Dublin. If facilities were moved to Cavan or Monaghan I envisage that it would be a great deal more difficult for the people in the hospitals further north to make use of help from Dublin which has been so efficacious in Navan.
There is also the question of visits by relatives to people in hospital. I realise that when patients have passed a critical period they will be moved back from the proposed regional hospital to rest homes but even so there could be many Meath people who would find it difficult to visit relatives in Cavan or Monaghan. These visits would have a useful medical effect because they would raise the morale of the patients and help their recovery. If the FitzGerald Report proposals are put into effect Meath patients would not receive as many visits from their relatives as they do at present.
I sincerely hope that in the future there will be developed in Navan centralised and computerised diagnostic facilities with a large number of doctors who will be able to specialise in the various areas and ensure that proper diagnoses take place. With the increasing complexity of medicine the general practitioner will not perhaps be able to cover the whole field and a specialised diagnostic service would be of great benefit. I hope the Minister will consider having such a service installed in Navan.
In this day and age, with the cost of health services both at local and Government level, we know that in a county like Carlow which has no county hospital, we cannot expect to have a general hospital of the type we would normally expect to have. For that reason we are, as Deputy Crotty said, in the south eastern region. We had a meeting with the Minister and his officials in Kilkenny. I agree with Deputy Crotty that this is the centre of the region and I hope it will be the administrative centre of the region and that Kilkenny will have a hospital also. As far as Carlow is concerned when we reported back to the county council after this meeting with the Minister and his officials the members were unanimous, irrespective of which party they belonged to or which area they represented, that Carlow, which has been traditionally associated with Dublin for extern hospital purposes, should remain in that area. This might mean cutting across county boundaries or it might mean a change in the south eastern region but the 21 members of Carlow County Council gave their views in a very constructive debate that they want to remain in the eastern region. For years the people of Carlow have been taken to the district hospitals, diagnosed and then sent to Dublin. It is hard to break with tradition.
The Deputy would seem to be outside the scope of the section we are discussing.
We have already dealt with health boards and there are more regulations about the health boards coming in later. This does not arise on this section at all.
The Minister gave us an assurance that he would have an inquiry before any hospital is closed. We accept that in good faith. I know the Minister is anxious to meet the wishes of the public representatives as far as possible. A strong case was made by Deputy Esmonde and Deputy Dr. Gibbons for specialist surgical services which could mean a saving of lives. I agree that that is true in certain cases but then we have specialist hospitals already. We have cancer hospitals in Dublin in which they carry out specialist treatment. We have a clinic for people suffering from polio and various other complaints. We have the Cedars in Dún Laoghaire where people come from many parts of Ireland for specialised treatment. If we are going to give our people specialised treatment, except in the cases mentioned by Deputy Dr. Gibbons, Deputy Esmonde and other Deputies, we should try to give them the best specialised treatment we can. Deputy Clinton, Deputy Dockrell and I, with other Deputies, have been trying to co-ordinate seven or eight hospitals in north Dublin with seven or eight hospitals on the south side. We are doing so because we want to give our people very specialised treatment and we do not want to have small hospitals duplicating expensive specialised equipment.
The Minister has tried to meet us fairly. I should like to see him being able to replace every county home in the country with modern hospitals. I visited a county home in another constituency recently and it is not fit to be open at all. We are trying to deal with a huge problem. The Minister has already said that this is an enabling Bill to make a start on the reorganisation and improvement of our health services.
The cost of the health services has gone up so much that we are always talking about it in this House. We want to provide the best services we can for our people. In Dublin we need to have a specialised general hospital to deal with specific prolonged diseases. This is a very involved matter. I admit that all Deputies can make a special case for keeping hospitals in their constituencies open.
We have been trying for the last eight or nine years to keep people out of hospital and to enable them instead to have treatment at home. The only way we can do that is to give some allowance to enable them to remain at home. If we give them £4 or £5 a week to remain at home it is cheaper than putting them into hospital where it will cost £15 to £20 a week to keep them there. I accept the assurances the Minister has given us.
I do not propose to delay the Minister long on this section but I should like an assurance from him that there will be no question of any of the hospitals in Dún Laoghaire being downgraded. I know it needs no words of mine to let the House know the good work which the medical profession and the nursing staff are doing in St. Michael's Hospital and the same can be said of Monkstown Hospital. Those hospitals are serving a large area. It is very difficult, with transport the way it is, for a person in that area who is brought into a Dublin hospital to be visited by his or her family or friends. I want to see the services which these hospitals are rendering at present retained for the people in that area.
I should like to say the same for the medical staff and the nurses in Loughlinstown Hospital, which is serving a growing area. I cannot refer to it as a rural area now because it is almost completely built up. I should like an assurance from the Minister that the Loughlinstown Hospital will continue to give to the people in that area the services that have been given to them in the past.
Mr. J. Lenehan
I can hardly be too critical of this Bill when I know that a hospital in Mayo is to be upgraded, not down-graded. I am glad to see the improvements this Bill envisages. However, I admit that this section is written in typical Civil Service language. It can be read so many different ways that some Deputies are doubtful about what the final interpretation will be. I would suggest, especially to Dublin Deputies, that they should stop throwing mud. We are living in an era of reports. We have the FitzGerald Report, the Devlin Report and I suppose it will not be too long until we get the Micky Mouse report. I never read those reports. We are inclined to be influenced by them. It is much better for public representatives to make up their own minds about matters and not be influenced by all those reports.
I remember on one occasion CIE brought over a man from British Railways to tell them what to do with CIE to make it pay. At that time CIE were losing about £500,000, and British Railways were losing about £50 million. This was the genius brought over to tell us how to make CIE pay. I consider all those reports are tripe. I would be dishonest if I said otherwise. There are not many fools here in this House. If they were fools they would not be elected by the people. Deputies should not be influenced by any of those reports. Most of them are written by alleged geniuses. Nowadays anyone who specialises can call himself an expert. I know a man who became an expert by the simple process of not drinking tea. He drank cold water instead and he is now a expert on brands of tea.
That does not arise on the section.
Would the Deputy give the brand of tea?
Mr. J. Lenehan
Bog water. A drop of whiskey in it would not do any harm. However, we have here the ingenious idea that the best hospital services are in Dublin. To some extent they are, but when country people want to get into one of the Dublin hospitals they very often have to wait six or nine months. I do not agree with what has been said here, that we should have a hospital at every crossroads. We would end up with a lot of tenth-rate institutions. If we are to put up more hospitals they should be capable of giving a first-class service. On the other hand, the background to this debate seems to indicate that either everybody in the country is already ill or is going to become ill. I do not think so. There are, these Deputies may be surprised to hear, a lot of healthy people in the country. It is an extraordinary attitude. We have seen commercialism and parochialism already in relation to the centralisation of schools. We had the "lollypop man" and the haircream men objecting because schools were being taken away from them.
Will the Deputy please come to the section? Let us have some progress.
Mr. J. Lenehan
I do not think I am very far from it. This involves the closure of hospitals and the rebuilding of hospitals. Do we ever think where we will get nurses to staff these hospitals by the time we have built them? How many nurses will we be able to get? Nurses are disappearing from the country as fast as they can. We are codding ourselves. One of the most ridiculous things is that married nurses who go into hospitals—they are doing a work of charity—must pay income tax.
This does not arise on the section.
Mr. J. Lenehan
If we do not get nurses, how will the Minister be able to carry out all these funny things?
We will never get through the Bill in this way. We are now on the Committee Stage of the Bill and this has been a Second Stage debate.
Mr. J. Lenehan
Some of the funniest statements I have ever heard were made here this morning and nobody objected to them—the speakers were allowed to go on until they finished. I suggest to the Minister that instead of reading the FitzGerald Report or any of these other reports about opening and closing hospitals, he should accept the views of the public representatives given to him at the various meetings which he attended. The Minister was very generously and graciously received by those people and he treated them very generously. The views that come from such people are much fairer and more valuable and will eventually benefit the people much more than a lot of the tripe and nonsense printed in those reports put out by people who do not know what they are talking about. We are the public representatives and the Minister should accept what we recommend instead of accepting the views of these lay television geniuses and self-appointed experts. It will not go down in this country.
You are the medical expert.
Mr. J. Lenehan
I am not an economist with a BA degree.
Deputy Lenehan should not describe as tripe something which he has not read.
Mr. J. Lenehan
I do not read tripe.
This section is largely concerned with the implementation of the FitzGerald Report and if it did not influence Deputy Lenehan it certainly influenced the Minister and a lot of other people. On this section it was inevitable we would have a lot of discussion because local hospitals are involved. We are fortunate in having in this House Deputies who are doctors as well. We have had very sensible contributions from Deputies Gibbons, Esmonde and Loughnane. Their contributions are helpful because they can look at the thing from the two sides.
From my point of view, the FitzGerald Report is an excellent document, although in Dublin we are not concerned very seriously with the problems posed; most of the difficulties will arise in the country areas. It is fair to say, however, that on the team which produced the report there was nobody but medical consultants and surgeons— there were no general practitioners. That was a great mistake because the general practitioners are the men who know the hazards and the difficulties with which we are faced. Nurses were not represented and neither was there an administrator on the body. The report was compiled in seven months and it is correct to say that some of the evidence was not 100 per cent reliable because the personnel of that body, excellent people though they may be, had not the time to visit the various institutions about which they were making recommendations.
I sympathise with the Minister in regard to this section because he has an extremely difficult job to do. One objection I have to the section is that it gives the impression that the Minister will have to do and decide everything and that if the boards do not do what he directs he will go the following morning with a flamethrower and burn them out. Of course, it is the manner in which the section will be implemented that will be important in deciding whether institutions stand or fall. There will have to be a very much closer examination of all the aspects of the institutions before decisions can be made, and my honest belief is that the Department as at present constituted are not equipped to carry out such an examination. Therefore, the Department will need all the assistance they can get from the members of the boards because they are the people who have the knowledge and the experience. This is a job that must be done very carefully because anybody with any experience knows there was a considerable amount of rationalisation and regionalisation required in the hospital service throughout the country.
People who have read the FitzGerald Report, which we are trying to implement by this section, will realise that it is as much concerned with the training of nurses and medical personnel as it is with the patients. This aspect may have caused too much concern but we all know there is a great shortage of nurses and that it is developing. One of the reasons why it is developing is that there are not enough of our hospitals large enough and with a sufficient variety of medical work to be done to train nurses. In other words, there are not enough training places for nurses. Every public representative comes face to face with this problem every day. A lot of girls have been trying to get into training and at the same time we have this acute shortage of nurses.
Therefore, the programme we should embark on must aim at building up the level of most hospitals to a good general hospital standard. This is desirable and it is something that should not be resisted. In the long run, the Minister personally will have to make the decision because it is always extremely difficult in a local matter of this kind, where there is so much sentiment attached to an institution, even when it is totally inadequate, to recommend a closure. It is easy enough to recommend that it should be built up into a sizable institution, and that may be the right thing to do in quite a number of cases, but it must be done by somebody who is a little remote from the situation. Let us be fair about it. We have to live as public representatives and we have to live with our neighbours, and as long as you have local attachments and feelings about institutions no action will be taken. In the final analysis the action must be taken by the Minister.
I should like this section to be worded in such a way that the Minister will not be directing everybody to do everything. If this is going to be the future pattern of things, and if we are going to have the Minister and the Civil Service telling area and hospital boards: "You will do this or that as we tell you, how and when we tell you", then by taking the entire initiative we will kill any interest and we will not get anyone worthwhile to serve on these boards.
Did the Deputy hear of the amendments I am putting in providing for local inquiries?
I am very pleased to hear that. This is the kind of assurance the people want, that the Minister and the Department will not be dictators. This is really important and it should be emphasised here. As I said before, the power is necessary but much depends on how it is wielded.
In discussing hospitalisation one is probably influenced by the outlook of the residents in a particular area and one expresses the views one hears in that area. In Clare the people are perturbed and alarmed that the FitzGerald Report has recommended the closure of the Clare county hospital which has been functioning for over 30 years. They are alarmed to find that this hospital is to be downgraded to a health community centre. One must ask the question why a report should be issued——
May I point out to the Deputy that there is nothing in section 37 that makes it easier for me as Minister for Health to close Ennis hospital. None of the Deputies seem to appreciate that. We are discussing the Committee Stage of a Bill and this Bill does not say that Ennis hospital is going to close. There is nothing in the particular section that even makes it easier for me to refuse grants for this hospital.
A Cheann Comhairle, are we not discussing hospitals?
Not in the way the Deputy is discussing them. It has already been pointed out to other Deputies that the question of regional hospitals does not apply.
May I ask when I shall have an opportunity to speak on the closing of hospitals in my county?
The Deputy will get an opportunity on Report Stage to deal with the matter to which he has referred. It certainly is not relevant on section 37.
I respect the ruling of the Chair and I will postpone any observations I have to make on this until a suitable time.
Other Deputies have been so informed also.
Question put and agreed to.
SECTION 38.
Question proposed: "That section 38 stand part of the Bill."
I am wondering why this is necessary. I do not know of any hospitals or institutions at present where arrangements are not made for religious services in a reasonable way. We have had this in the past and it is well to safeguard against it in the future.
This is merely repetition of a section in another Bill. I do not really believe it is essential but the draftsmen say it is necessary to put it in.
Question put and agreed to.
NEW SECTION.
I move amendment No. 42:
In page 21, before section 39, to insert the following new section: 39. (1) A health board may, on the request of a body which provides or proposes to provide institutional services or any other service similar or ancillary to a service which the health board may provide, and with the consent of the Minister, provide for the body any land which is shown by the body, to the satisfaction of the health board, to be required for the efficient performance of the functions of the body.
(2) Where a health board decides to provide land under this section for a body, it may acquire the land either by agreement with the consent of the Minister or compulsorily under Part VIII of the Health Act, 1947, and may lease such land to or for the benefit of the body.
(3) Where a health board is requested by a body to provide under this section any land for the body, the board may, as a condition precedent to its so providing the land, require the body to undertake to defray the whole or part of the cost of so providing the land.
The purpose of this amendment is to widen section 39 to permit that a health board can acquire land for bodies operating services outside hospitals. Deputy Ryan made a suggestion in regard to this on Second Stage and he was quite right. The section was too restrictive. This will permit health boards to acquire land for bodies operating services outside hospitals—bodies engaged on work for mentally-handicapped people, and so forth.
I take it this is something similar to local authorities being able compulsorily to purchase sites for schools and so on. It is really for the exercise of compulsory acquisition.
Yes.
Question put and agreed to.
Acceptance of this Amendment involves the deletion of section 39. Amendments 43 and 44 in the name of Deputy Ryan have been ruled out of order as they would involve a potential charge on State funds.
SECTION 40.
I move amendment 45:
In subsection (1), page 22, line 7, to delete "advise the Minister on the regulation of" and substitute "regulate".
The proposal to form Comhairle na nOspidéal was one of the recommendations of the FitzGerald Report, namely that there should be a central council co-ordinating and integrating the appointment of consultants and senior para-medical staffs for local authorities and voluntary hospitals. The main object, which I think was accepted by all on Second Stage, was that consultants should pull together, that they should be enabled to operate in a more flexible fashion throughout the country and in future the organisation of consultant staff should be such that the full use of available hospital facilities should be achieved to the best possible degree. One of the objectives was to expand outpatient diagnostic consultant services throughout the country so that whatever concentration of facilities was required for acute surgical and medical cases it should be possible for people to get better consultant services and to be able to see more than one consultant when required.
As the House knows the whole bent of modern medicine is towards greater specialisation. The consultant gives advice, the patient already having attended the family doctor whose services are absolutely vital in this connection. This is proceeding regularly and, moreover, the Todd Report which I think will be implemented in Great Britain and which will have its inevitable repercussions here, provides for medical teaching to be based on advising all medical students of the likely openings in the various specialities and in screening them so that in relation to, for example, the inadequacy of radiologists at present and, in this country, of pediatricians and even of psychiatrists, medical students who finish their first degree of university training will be given advice as to the kind of specialities they should follow.
This, in turn, will encourage what might be described as a minor degree of specialisation in the case of certain doctors who will remain family doctors and go into group practice, and greater specialisation in regard to those who want to become senior consultants. The period of training will be very long and because of this it is felt essential to have this central body and, in the second stage, it is suggested that the body might advise the Minister and be advisory in character. My predecessor and I have had this matter examined and in view of the fact that about 50 per cent of the people who go to hospital from local authorities under State payments go to voluntary hospitals, it was felt that for me to take responsibility for taking the advice and making the final decision in regard to all these appointments would be impossible and that, therefore, this board should be given the actual power of making decisions.
The constitution of the board will come before this House in the form of resolutions that will be discussed in regard to the formation of the board, its constitution and its procedures. It is clear that the medical profession will have to be consulted at every stage in regard to this matter. Comhairle na nOspidéal will work in the first instance to regulate consultant posts throughout the country but it will not select personnel. Selection will continue to be done by various methods which are known to most Members of the House. There will be some slight changes inevitably because of the formation of the regional hospital boards. When Comhairle na nOspidéal has made a proposal for the appointment of a consultant to perform purely non-teaching duties, a consultant to work in a non-teaching local authority hospital such as the appointment of a new county surgeon, the appointment procedure will be based on the existing Local Appointments examination and so on. If Comhairle na nOspidéal recommends the appointment of a consultant to work in a teaching local authority hospital there is already a procedure for the selection of such a person in section 62 of the 1953 Health Act; in other words, a selection board set up by the Local Appointments Commission consisting of two members selected by the teaching body, two members selected by the Local Appointments Commission and a chairman selected by the Minister. That system is operating, as far as I know very satisfactorily.
If the appointment is to be made for work entirely in a voluntary hospital the existing procedures which vary from hospital to hospital, particularly where a teaching body is concerned, will continue. There are other cases where, in order to have more intergration and co-ordination, Comhairle na nOspidéal might recommend that a consultant be appointed to a local authority hospital and also do work in some voluntary hospital in the district or wherever they consider this to be a good thing. In that case, the Local Appointments Commission have a special procedure if this consultant's services are to be accepted on an agreed basis in the voluntary hospital as well as in a local authority hospital. Equally, one could envisage a situation, which already occurs now, where an appointment had to be made in a voluntary hospital but where clearly a considerable amount of the time would be spent by the consultant in a local authority hospital on a sessional basis. Again, Comhairle na nOspidéal would have to recommend a form of procedure that would be satisfactory to both parties.
I think I have made that position clear. We are now in an interim period. It is hoped at a later stage that Comhairle na nOspidéal will set up its own special selection procedure for these consultants which will be on a basis that will ensure the same kind of impartiality as is now possible with the Local Appointments Commission. That will come only after consultation with all the medical interests involved. When the resolutions come before the House for the procedures in relation to the setting up of Comhairle na nOspidéal and the regulations in regard to the appointment of their own staff— this also applies to the regional hospital boards—they will only deal with the body as one to regulate the number and character of the posts. They will not deal with the selection procedure which will have to come up a year, 18 months or two years from now after consultation with the medical profession on the actual method of selection for posts as consultants.
I have given the House a fair idea of the reason for the change in this. I might add that the reason is that the cost of hospital services is enormous. Out of the total cost of health services, the cost of hospital services has reached a figure of £40 million. When I read reports on hospital services in countries far wealthier than ours, I find there is an enormous financial problem and that even in the case of a country like Sweden where they have managed to solve many of their social welfare and health problems and have a very advanced hospital service, they regard the cost of hospital service in relation to their economy as enormous and they are frightened by the number of bills involved and the capital costs of such future construction as they deem necessary.
The same is true here. The economy is advancing and production is growing but, nevertheless, we must ensure that we can continue to improve the character of our hospital services so that we can provide more and more specialist treatment of a multiple kind with several consultants examining a patient in a very detailed way in the case of many maladies. We want to continue doing that and we also want to make economies by having the system of consultant practice rationalised as far as possible so that every consultant can work most effectively. This also relates to the fact that it will not be possible to get these specialists unless they have enough work to do. No specialist would take up a post—this is increasingly the case and will become more and more the case in the future—unless he or she has enough work to do. The population is scattered and there are concentrations of population. It has been possible to work out approximately the number of beds required in relation to certain maladies, based on British or Swedish experience. There may be variations here; there are some, but they are not very great. So, we can make use of these calculations to rationalise the use of consultant services to the greatest possible extent by making them mobile, by requiring that they move around the country. I am very glad I have been able to get the agreement of the Medical Association and hospital interests in regard to the formation of Comhairle na nOspidéal.
They are willing to accept Comhairle na nOspidéal as a regulator, and they are also willing, in view of the very great difficulties in doing anything else, that I should be able to appoint the first comhairle. Consideration will be given later to who should appoint the second comhairle. I can assure the House that my appointments will be based upon a very wide knowledge of hospital practice. They will have to include a number of consultants of various kinds. They will have to include consultants from the three regional hospital board areas, and they will also naturally include some officers of my Department.
As I have said, the characteristics of the comhairle will have to come before the Dáil in the form of resolutions after this Bill has been passed. As well as that, the regulations for the appointments of the regional hospital boards and their procedures will also come before the Dáil in the same way at a later stage.
The amendment proposed by the Minister is important with regard to the making of appointments to the service. I was very glad to hear that the Minister has given various undertakings in relation to the closing of the local authority institutions. I have a lot of sympathy for him in his problem on this particular issue because, to use a cliché, we are at a watershed and in a very important changing period in the whole organisation of our health services. It is very difficult for anyone to be quite certain as to what are the real needs of the community health services in the future.
We have many reports at present. There is the FitzGerald Report, the Todd Report, the Gills Report and the Mellaby Report. Most countries are attempting to alter—I was going to say upgrade, but I think the use of the word "downgrade" in the FitzGerald Report was most unfortunate—their services in a way which will meet the great changes which have taken place in medicine in the past 20 years. No one can claim infallibility. All we can do is read all these reports—I do not agree with Deputy Lenehan; I think we should read them—and, from our own experience, put our conclusions at the disposal of the Minister. It is he who has to take the important decisions finally.
This was the decision which was taken about 30 years ago. I think it was a correct decision at that time: the grouping of the county hospital, the district hospital and the regional hospital, based on a single general practitioner, or a pair working in partnership. That is all going now. There is a great reluctance on the part of everybody to see any change, because there is a great sense of security in knowing that there is a doctor and a hospital quite close to you. The pattern is changing. It is important for the layman to try to understand that the pattern is changing in his interests, and that it is not being changed just for the sake of change. It is being changed to make the services better for the community generally.
I was very glad indeed to hear that the Minister has not closed his mind on the question of the FitzGerald Report, that he will use the best part of it, that he will try to extract the best part of it and use it, and that he will reject what he does not think is applicable. The basic proposal which I should like to put before the Minister on this section is the idea of trying to move away from the hospital orientation which I myself had 20 years ago when I was responsible for many of these hospitals, and which I think must change. In the Twenties my predecessors, Dr. Ward, Seán MacEntee, Seán T. O'Kelly, and those on the Cumann na nGaedheal side too, had to accept the fact that there were at that time pretty poor communications, that hospitals in different areas were inaccessible, that there were poor ambulance services and that medicine was at a fairly primitive level. One has to admit that surgery was at a fairly primitive level. That is all changed now, and the idea that the services should be based on a hospital will have to be changed.
That does not mean at all that the small hospital is to be downgraded. That is an unfortunate word. It simply changes its role in the new set-up. It is for that reason that I was anxious that the Minister should, instead of restricting it to "advise the Minister" on making appointments and so on in hospitals, also include "and other medical appointments" of those engaged in the service.
Quite clearly there is to be a complete fragmentation of medical care as we know it now. Many Deputies were genuinely concerned because they felt that if a hospital is 60 or 100 miles away the people they represent will suffer in consequence. Our county hospitals have done wonderful work under great difficulties. Most of the county surgeons, county physicians and anaesthetists worked under most undesirable conditions. They worked long hours, not only long hours on active work but long hours with the responsibility of knowing that they had to be available.
Hospital procedures now have become very much more complex than they ever were before. One now finds that most serious surgical procedures are the work of a pretty complicated and pretty large team encompassing everything from the diagnostic side right through to things like blood transfusions, blood typing, and transplantations. All of these procedures are enormously complicated and they simply cannot be provided in the smaller type of hospital.
The first great change has been in the quality of medicine and surgery. Enormous strides and advances have been made. Secondly there is the physical change in our community in so far as we have very good communications, generally speaking, throughout the country. One can get from one place to another pretty quickly and, when one does get to the point to which one is trying to get for the sake of the individual in the ambulance one gets such a level of service that it is well worth the difference which would be involved in the distance if the person were being brought to a small hospital.
Incidentally, the Minister will probably be concerned to greatly improve the quality of the ambulance service. This would have to proceed pari passu with an alteration in the role of the county hospital. They are reasonably efficient; they are not as bad as people say they are, but they can be greatly improved, and the ambulance equipment could also be improved. However, the main concern is that the Minister would not restrict this Comhairle na nOspidéal to the role of concerning themselves with the hospital. I want to try to persuade the Minister to re-orientate himself into the concept of the community approach to the health services, that these small hospitals will become very active, vital, health centres that you will no longer have the general practitioner on the corner, no longer get the small partnership, that there will be seven, eight or ten doctors working in groups in a health centre. I never understood how the general practitioner was able to take on the great responsibility which he frequently must face unsupported by the tremendously valuable hinterland of the scientific and technological information which is available to most doctors working in hospitals. There will be this health clinic providing complex scientific and technical diagnostic services, as Deputy Bruton suggested, computerised diagnostic services which will make available very rapidly to the practitioners in the group the information which will help them to come to a reliable conclusion as to what the patient is suffering from.
Deputy Ryan made the very good point that many of our hospital beds are filled with people who should not be there at all because they are simply waiting around to have some diagnostic procedure carried out. Although it may not be deliberate, there is a misuse of beds. We should develop this community concept in the approach to our health services so that the general practitioner is supplied with top quality technicians, radiologists, radiographers, laboratory assistants, all the resources of a blood transfusion service and so on. If we had all these facilities available, then we could lower very much the great pressure on many of our hospital beds.
If we disposed of the Minister's amendment, No. 45, and the other amendments, we could go on to the section and deal with the questions mentioned.
I was not sure whether the Minister was dealing with the section or the amendment. I welcome the idea in the amendment. I had intended to put down an amendment myself if the Minister had not done so. It is an advance on "to advise the Minister". Reading through this Bill, it seems to me to be a sort of bureaucrats' charter in so far as there is very little left to the public representatives, that whatever powers they did have are even further reduced, and that the only people that seem to matter in the new Health Bill are the CEO and the Minister for Health. While I know quite well the record of the local authorities and their activities over the years which led to many of them having to have powers taken away from them, I myself am an absolutely immutable believer in the concept of democracy. The less power we give to local representatives, the lower the quality of the people who will come into the local authorities. People will not come in simply to spend hours debating an issue and then find the CEO or the Minister changing the whole decision simply because he does not agree with it. The change in the local authority status was probably inevitable because of the behaviour of many of them, but we are changing very rapidly as a community generally. Anybody who watches the change in the quality of this Dáil and the change in local authorities generally—I hate to sound supercilious about it—knows that there is a much better educated person coming into public life and into the local authority.
I do not think it arises on the Minister's amendment. That is the only question before the House.
It arises in this way, that before the Minister had down "to advise the Minister". Where there is a question of advice he can ignore the advice. Therefore, the Minister's amendment to the effect that the council would determine appointments is an advance on the previous proposal. The idea that this council should be simply an advisory one is a bad idea, and wherever it occurs I would disagree with it. Over the years there have been various advisory bodies, national health councils and so on, in which advice was frequently given and nearly equally frequently ignored by the Minister. I think this is an improvement as long as the Minister intends the phrase "to regulate" to mean to determine, that is to have a final decision on the number and type of appointments which I think is implicit in the word.
If I understand the Minister's amendment, the purpose of it is to take away from the Minister the regulation of the number and type of appointments of consultant medical staff and to give this power direct to the council itself, which will say where and when appointments should be made and the Minister as such will not have any function in relation to that. If it is otherwise, I should like to know.
That is the case except, of course, for the inevitable millstone that hangs around the neck of every Minister for Finance, the availability of finance. Obviously, the consultants have to be paid for and the capitation fees for patients receiving health services in voluntary hospitals have to be paid for. There is no country in the world, east or west, where budgetary control does not ultimately have its influence.
Yes, but there is no restriction here in relation to what the council may regulate. The council will regulate the number and type of appointments and, no doubt, the council will have regard to what the budgetary position is.
The House will also appreciate we are attempting what might be described as an elaborate pattern of hospital administration by decentralisation and by communication. We have the health boards and the regional hospital boards and we have an comhairle. Obviously an comhairle must consult the regional hospital board and, in turn, the regional hospital board will have representatives of the health board.
This will have to be a careful operation, otherwise the council could be intensely resented. The operation of the council will depend on the understanding it has with the regional hospital boards, the health boards, and in particular the understanding it has with the voluntary hospitals. The voluntary hospitals have given wonderful service in this country but their representatives now recognise that there must be growing co-ordination and integration under the circumstances of medicine at the present time, which have been very well described by Deputy Dr. Browne. Everything he has said relates to the most modern view of medical practice. It would be wrong for me to speak of the powers of the council without referring to their co-ordination with the regional hospital boards and the health boards.
If the Minister hands this power over to the council how does he retain any power under this section?
I retain the power first of all because there must be an overall budget. The regional hospital boards' duties will be to plan and perpare the organisation of the operation of services both in the voluntary hospitals and in the local authority hospitals in their region. For the first time it is proposed that they themselves, on the recommendation of the council, could pay for the services of a consultant working in a regional hospital area who would move around the area and who might work either in a local authority hospital or in a voluntary hospital. The regional hospital board would be the first employer of the consultant and they would have to be recouped from the health board and the voluntary hospitals for a proportion of the expenditure. The regional hospital boards will have a very important function and it is essential that the council keeps in touch with them.
In regard to budgeting, before the beginning of each financial year the health boards in the regional hospital board area will present their budgets in so far as the hospitals are concerned to the regional hospital board. The regional hospital board will also receive from the voluntary hospitals in their area the voluntary hospitals' budgets. The regional hospital boards will examine these budgets and make their recommendations which will, in turn, come to the Minister for Health. The Minister for Health will consider the matter in relation to the total budget and then send back the budgets to the boards. The object of this exercise, which is novel, is to try first of all to secure a basis on which the central council look at the situation over the whole country. They can consider the operation of these services regionally and then the operation of services in the regional boards. This is an exercise in decentralisation and co-ordination. I hope I have made the position clear.
The Minister has said that the members of Comhairle na nOspidéal would be drawn from regional medical people. Does this mean there will be no representative from the future county hospitals, from the medical association or from general practitioners? The Minister has said that the local Appointments Commission will be responsible for the appointment of what we now call the county physician and the county surgeon whereas there will be a different system of appointing people who are expected to teach. I would recommend the Minister to ensure that all those appointed should be able to teach and, having succeeded in this, he should make it part of their duties to have them teach on one or two occasions in each year.
I envisage the situation where the hospitals in places like Sligo, Castlebar and Roscommon—if it is lucky enough —would hold post-graduate courses once or twice a year. If the Minister accepted that this was administratively feasible, naturally the onus of producing the programme would fall on the county surgeon, the county physician or the county obstetrician. As I see medicine evolving, and Deputy Dr. Browne has indicated at length the changes which are taking place, teaching at local level will become more and more important because the amount of literature being published is something that no one person could read and absorb. I do not think this system of teaching at local level obtains in any other country in the world. Knowing the Minister as I do, I feel that, if I can convince him that this would be of tremendous advantage to the general practitioners, private practitioners and even county surgeons, he will consider it seriously and try to draw up something along these lines. There is no doubt whatsoever that this is one of the easiest ways of exchanging knowledge.
I agree entirely with the Deputy. One of the proposals in the FitzGerald Report, which no one would disagree with, is that general practitioners should play a greater part so far as rights of entry into hospitals are concerned. The report suggests that they should play a greater part possibly in district hospitals and general hospitals. This has progressed in certain hospitals but obviously it needs much more attention. The FitzGerald Report points out that existing general practitioners who work very hard in isolated districts have not the opportunity in many cases of doing ward-rounds with consultants in county hospitals in order to see new treatments and new techniques.
I have already stated that I regard the development of the choice of doctor administration as essential in this country. We have got to have built into that, at some stage or another, an arrangement for regular refresher courses. Having read the Edinburgh and Manchester reports on the method of apprenticeship for general practitioners, I feel that apprenticeship methods of general practitioners need reconsideration. Indeed, the Irish branch of the Royal College of Physicians has made some excellent proposals about improving training in that regard.
Comhairle na nOspidéal and the regional hospital boards will naturally take account of that in their decisions. I will be responsible for negotiating the fee for service arrangement, which is inevitable, with the choice of doctor system. I am not saying that I could begin to do this right away but I shall have to consider how far the opportunity for refresher courses could be evolved. Some doctors are very much overworked and it might be difficult to replace them for a long period. Nevertheless, I regard it as one of the objectives of my term of office that I should undertake the improvement of the two matters referred to by Deputy Dr. Gibbons.
I rise for clarification of the Minister's amendment. It seems to me that the Minister is divesting himself of authority. In other words, he is decentralising. No one would disagree with that. This amendment deals largely with the voluntary hospitals and Comhairle na nOspidéal, which will have control over the local authority hospitals. The governing bodies of the voluntary hospitals will still exist. With regard to the employment of consultants, where you have such a system of dual control, there is always the possibility of disagreement between the interests involved.
The Minister is divesting himself of authority. If there are two separate bodies dealing with a problem it is usual to have a titular head as a means of final mediation between them. According to the Minister's amendment, he goes out of the picture altogether except that if they do not agree among themselves, supposing the governing body of the voluntary hospitals are forcing a point that the Minister considers not to be to his satisfaction or to the best interests of the medical services, he can withhold grants which I think come from the Hospitals' Trust, and, likewise, if Comhairle na nOspidéal do not agree to do what the Minister considers they should do he can withhold money from them. Am I right in thinking that that is his sole function in regard to any differences that may arise between the two boards? If it is, then we may be facing considerable difficulties in the future. I am the last person to look for severe ministerial control but the control in this section is rather nebulous. The Minister should keep to himself some limited control without interfering in the minutest degree with the two boards that he is setting up. He should not leave it the way it is. In the case of a dispute there would be doubt about to whom they should go for settlement. It would seem that the Minister would simply say, "A plague on both your houses. I will stop your grant." I may have misinterpreted the intention behind the amendment. If I have not, the Minister should elucidate the matter.
There is something in what Deputy Esmonde says. This amendment is rather woolly. Its implications are not clear. Is the Minister not, in fact, retaining a right to vote on the number and type of appointments? If he is, how is he going to do it? Is he not laying in store for himself an enormous amount of responsibility? Presumably, each regional board will have to submit their proposals to him for sanction and he will have to concern himself with everybody from the hall porter to the consultant pediatrician and so on. Would it not be wiser for him to accept that this is a very responsible board that he is establishing and that they would work within a particular budget and that they should then have the responsibility of making decisions in relation to appointments and be restricted by the particular budget? The budget would be a global one and they would work within that global budget and would then have to cut their cloth according to their measure. It seems to me that the Minister will find himself saying to one of these regional boards "You want another pediatrician. I do not think you should have one." Is this going to be the position or is the Minister simply going to give them a global sum and tell them to get on with it or will he inspect each single appointment within the ambit of responsibility of each board?
In reply to Deputy Browne, it is proposed to give a global sum in this connection and Comhairle na nOspidéal will obviously have to operate their regulatory device bearing in mind the budget situation. I am quite aware that the working of Comhairle na nOspidéal will be extremely difficult. This will be a test of character not only of the members of the comhairle but of all the voluntary hospitals and the local authority hospitals that are concerned in their recommendations. I have seen in my career, and Deputies have seen, boards of a similar kind who managed to operate successfully, managed to do a tremendous amount of good in this country and who had to exercise the same sort of tact and understanding in the discharge of their duties. I am quite certain that there will be difficulties and I am quite certain that I am going to have rows when this body gets into operation and until it finds its feet and until people all over the country begin to accept the fact that the health services are one, in one sense; that they are regionalised in another sense and further regionalised in another sense and that then you come down finally to the GP and public nurse working in a rural area. It is this total concept that has to be considered. That is the position. They have to work within the budget. I hope the budget will be expanded as the years go by. I hope it will be expanded partly because I really do believe that if we spent more money on consultants and on good laboratory facilities in hospitals we would reduce the cost of keeping people in hospital and of keeping them too long waiting for beds in hospitals, as mentioned by Deputy Tully. Nevertheless, it is going to be a very expensive business. I do not think I can go into it in any further detail than that.
As I have said, the method of appointing the comhairle will come before the Dáil in the form of a separate resolution and also the method it will employ in appointing its own private staff. So that the House will be able to discuss this body again.
Would the Minister not indicate who is responsible for settling any disagreement that may arise? If you have two separate bodies you must have some sort of titular control over it.
It is quite clear from the amendment that the comhairle has the ultimate responsibility and the ultimate decision. When it makes a decision about the appointment of a consultant, the health authority or the voluntary hospital will have to accept that decision. That is the kind of executive decision which I am going to entrust to this body. I am going to find about 24 or 25 people to do this work and I do have enough faith in the medical fraternity of this country to believe that I can find people who, along with some officers of my Department, will be capable of doing this work effectively and capable of exercising tact and of understanding particular and difficult situations. I would have to give them the authority. It would be quite impossible for a Minister to exercise this final regulatory authority. When you consider the different interests of the voluntary hospitals and the local authority hospitals all around this country it would be absolutely impossible for me to do it. There would be emotional pressures of every kind, personal pressures of every kind, exercised upon the Minister for Health of the day. So, the Minister must delegate this authority and I, naturally, will have to keep in touch with the comhairle through the officers of whom I imagine there will be at least four from my Department. The officers who are most skilled in the development of hospital services will be chosen for this purpose.
I can look back on my experience with eight State companies. Although there has been criticism of these companies, as well as a great deal of praise, on both sides of the House, I found that the most important thing of all was one's personal connection with the board through meeting the members on occasion and discussing matters with them in a general way. That personal connection is very important. That was stressed by Deputy Ryan and others in the case of those who are sick. The personal connection between the Minister and this new board will be very important to ensure that the Minister will have a proper understanding with them and they with him in this entirely new procedure designed to bring local authority and voluntary hospitals into closer contact in operating together and co-operating together.
I do not disagree with anything the Minister has said, but am I to take it that Comhairle na nOspidéal will be the senior body and will have some jurisdiction over the governing bodies of the hospitals in relation to consultants?
Only in relation to the appointment of consultants, not in relation to the governing of the hospital.
Amendment agreed to.
I move amendment No. 45a:
In subsection (1) (b) (i), page 22, line 10, before "engaged" to insert "and other medical appointments of those".
I have already indicated my reasons for tabling this amendment. My purpose is to enable the board to adapt itself to realities. There will be a complete breakaway from the strictly hospital orientated type of service. The general practitioner will be, as the Minister said a moment ago, a completely different kind of person; we will have a consultant general practitioner just as we have the consultant surgeon at the moment. General practice is very, very complicated and no individual could possibly have all the knowledge required. One could not have the knowledge available to doctors in respect of the different medical traditions, and, because of that, there is not likely to be much more specialisation amongst general practitioners. There will then be the status of the consultant general practitioner. He will have the right of access to the hospitals. I was very keen on that myself but I did not have the courage to try to bring it about. It is overdue now because of the changing status of the general practitioner. There is bound to be an expansion of the specialist type services, like the prison service, and the paediatric and geriatric services, so that there will be a great many changes leading to the development of specialisation in health clinics outside the hospital and it would be wrong, therefore, to isolate the powers of Comhairle na nOspidéal to functions within the hospital. I do not want to labour the point. I believe the Minister agrees with this. It would be better to give that body the right to make the appointments for the total service rather than for one particular sector.
While I sympathise with Deputy Dr. Browne's concept of what might be extended powers of Comhairle na nOspidéal, it would be quite impossible to accede to this request. The district medical officers and the general practitioners who will take part in this scheme will be under the control of the regional health boards and they will be able to cross the boundaries of existing county health authority areas. The arrangements for the choice of doctor appointment will be done by regulation under section 56, which will come up for discussion later. There is nothing to prevent Comhairle na nOspidéal giving advice and co-ordinating consultant appointments. This is simply a question of management. One draws lines so that management will be both effective and practicable. It would be quite impossible for Comhairle na nOspidéal to deal with such a large number of appointments, some 1,200 in all. I would not consider it wise to control the number and type of appointments to the medical officer service of health boards. Possibly the Deputy was thinking more of co-ordination between consultants and medical officers. The actual appointments should, I think, be done at local level.
I am in agreement with the Minister here. On reflection, Deputy Dr. Browne may find that he will defeat his object rather than achieve it were he to take away from health boards and confer on Comhairle na nOspidéal the power to regulate appointments extra-murally. Comhairle na nOspidéal is concerned with institutional personnel and if social and general medical services are to be available they must be based on local knowledge and local concern. This amendment would only delay appointments and, goodness knows, appointments are slow enough at the moment. The situation would be intolerable if they had to be put through the conduit pipe of the medical hierarchy. There is already ample scope for consultation at the proper level in connection with the appointment of medical and other staffs outside of the hospitals. It would be a pity to draw that, from its large field of local responsibility, into a board which would probably sit in Dublin and which would be far removed from local pressure—and I use the word "pressure" in a flattering and not in an offensive sense—because if there is local pressure it means there are local demands for services. That is where services required locally are determined and not through a national body of the nature of Comhairle na nOspidéal. I think the section would be best left as it stands.
I am more concerned with getting an idea of the Minister's attitude and I do not wish him to feel bound, as it appears to me the FitzGerald Report was bound, by this obsession with the hospital as being the centre of the health service. It is not, but it is a component and an important component, but all the others are equally important components. If it is broken up in such a way that there is to be priority—this was implicit in the use of the word "downgrading"—then I should dislike the Minister to continue to accept that attitude in regard to centralisation. Does the Minister propose breaking up the LAC, the central authority in Dublin which already makes these appointments?
Section 56 would account for the question of a choice of doctor and naturally the Local Appointments Commission will continue to operate in the appointment of dispensary medical officers for permanent posts, such as those that are required, but when it comes to the selection of those general practitioners who wish to partake on a fee-for-service basis one could not make use of the same procedure. There will, therefore, be some sort of special selection procedure devised, regulations for which will be placed before the House. It would not be possible to make use of the local appointments procedure in regard to the choice of general practitioner who had served in an area for a long time or at least for two years, and who would be willing to accept the fee-for-service principle and to help those with medical cards.
It is all centralisation at present. Is it not on the lines of the communist concept?
I will not try to discuss that concept but it seems to me that some of what Deputy Dr. Browne has in mind might be achieved if, in the selection of personnel for Comhairle na nOspidéal, some appointments were to be given to general practitioners, to medical social workers, to people who are actually involved in this type of activity which needs to be considered. It would be undesirable that Comhairle na nOspidéal should be composed only of hospital consultants and officers from the Minister's Department because that might well be at variance with developments in the wider field of medicine, whereas if the right views are represented on the board there is a reasonable prospect that the disciplines which Deputy Dr. Browne has in mind would be in the minds of those on Comhairle na nOspidéal, providing they would make new regulations.
Amendment, by leave, withdrawn.
I move amendment No. 46:
In subsection (1), page 22, lines 20 and 21, after "prescribed" to insert ", after consultation with the Council and with such bodies engaged in medical education as appear to the Minister to be appropriate,".
This is an amendment which is essential although the effect of it will not operate for some considerable time. It has relation to the power it is proposed to give to Comhairle na nOspidéal in making selections of consultants particularly where their functions involve work both in voluntary hospitals and in local authority hospitals, or in a group of voluntary hospitals. These matters must come before the Dáil. The first stage is only concerned with the actual structure of Comhairle na nOspidéal and its procedures for regulating as distinct from selecting. This is to ensure that there will be consultation with the authorities engaged in medical education before any arrangements are made for the selection procedures. It is not an urgent amendment but it must go into the Bill.
Amendment agreed to.
I move amendment No. 46 (a):
In page 22 to add to subsection (1) (b) the following:—
"(vii) the selection of and procedures to be adopted in relation to consultant medical staff".
This is a suggestion that we should allow Comhairle na nOspidéal to have the responsibility in the selection and laying down of regulations and which will select the procedure to be adopted in relation to the consultant medical staff in regard to both local authority and voluntary hospitals. Most of the money now used by voluntary hospitals is money that comes from the health authorities or from the Hospitals Trust Fund or from central funds, and for that reason it would be more democratic if we were to allow the Comhairle to have the right to decide on this question of procedure in relation to the making of appointments. The Minister showed some sympathy with this idea when he pointed out that the old idea of voluntary hospitals has changed completely.
The Deputy may be assured that that is already possible through section 40 (1), subparagraph (5).
There is a difference between possible and prescribed.
It is possible. These functions in relation to the consultant medical appointments should be worked out carefully in accordance with subparagraph (5), after consultation with all the interests concerned, and, in fact, these regulations will come before the Dáil.
The Minister will agree that it says that the function of the council "shall" be with regard to, but according to the Minister it "may" be with regard to.
It is that dreadful use of the terms "may" and "shall" that have defeated me for as long as I have been in the Dáil. I will have a look at it on Report Stage. I suppose most Members of the House know that the word "may" according to the draftsmen does mean "shall" in a great many cases.
It may mean "shall". That is what we are worried about.
Even the judiciary are not universally of that opinion.
They disagree too?
Amendment 46 (a), by leave, withdrawn.
I move amendment No. 46b:
In subsection (1) (c), lines 27 and 28, to delete "registered medical practitioners engaged in a consultant capacity" and substitute "comprised of all occupations engaged".
I should like the Minister to give us his ideas on the reason for this preponderance of the consultant in this type of body. Prima facie, I suppose one could say that the doctor is the ideal person to dominate an organisation of this kind but it is not as simple as that. Naturally, as a doctor and also as a specialist, I have no grudge at all against doctors or specialists. However, I know enough about our profession to be aware that we are really craftsmen in a very narrow sense. We know our own subject. A specialist is said to be somebody who knows more and more about less and less. To that extent, we may know our jobs extremely well and practise competently. That does not necessarily mean that we are good administrators. It does not follow that a person who is, say, an ENT man knows much about paediatrics or geriatrics; that a geriatrics man knows very much about psychology; that a surgeon knows very much about general medicine, and so on. I cannot see the special qualifications a consultant has which would merit so many of them being on this body.
I can quite see that there should be a specialist or doctor on a body of this kind. If a doctor is a good administrator put him on it but not just because he is a consultant. I set up many boards —the blood bank, the cancer body, BCG, boards for the building of hospitals and so on. I usually included a doctor but I did not feel I had to have half the board composed of doctors. The record of my profession over the years is not glorious when it comes to the question of progressive or radical health legislation. It seems rather absurd to accord to them this very great power in a body to which they are so closely linked and with which their financial interests are so closely linked.
I know that the average doctor simply works in a team composed of everybody—ambulance drivers, theatre nurses, nurses generally and adminstrators—and that each one of these people knows his job well; he is an essential component in the total structure which is the hospital. In my view, one person is as important as another in the team: one cannot go on without the other. If there is to be representation on Comhairle na nOspidéal, it should be representation which is representative of the whole hospital.
The Minister has been a very short time in the Department of Health. He may not have such a sanguine attitude to the medical profession after a year or two, by the time he is finished with his negotiations, particularly in relation to remuneration, and so on. Over the years, with different Ministers with different outlooks, the position has not been good. The general attitude of the doctor, the specialist and the consultant in particular, has not been a progressive one in relation to the health services.
I should not be taken as damning the whole medical profession. There are marvellous people working in medicine in consultant capacity as well as in general practice. The medical practitioner likely to end up on Comhairle na nOspidéal is likely to be a person who is not particularly disposed to consider even the mildly radical proposal—and, God knows, they do not go very far in this Bill. The Minister is cutting a stick for himself and he may very greatly regret it if he does not dilute very much more the doctor content and particularly the consultant content of this board.
This sort of thing smacks in many ways of a sort of vocational organisation. If the Minister wants to take professional advice, let him do so but not in this sort of overdose since it could quite easily lead to great trouble for himself. I am not so worried about the Minister being troubled. I am worried that we may not get as good a service as we would if we were to take people from the total hospital service who know it from every aspect —the nurses, the general workers within the service, the people in industry, the general practitioner from outside as well as the consultant. The Minister would be well-advised to examine the position of this body and to reduce considerably certain proposals he has for it at present.
I agree entirely with Deputy Browne. The Minister should listen very carefully to his remarks. They are all the more convincing when they come from a medical man and a specialist in his own line. I have seen a good deal of what he talks about.
I think that medical people are too close to the subject when they are appointing medical people; that they are too close to the pressures from medical people and that their decision therefore is often not the best decision. If an attempt is being made to make an impartial appointment, an outside assessor should be brought in. There is more merit in that than in bringing in people to make radical decisions for medical people. A preponderance of medical people is proposed for this board. That is unwise and it is unwise for precisely the reasons given by Deputy Browne.
There is a lot in what Deputy Browne says. At the same time, I believe it is possible to choose the kinds of consultants who are advanced in their views and who think radically: I know they exist and so does the Deputy. If you choose consultants in varying disciplines, some of them will come from different parts of the country. You then get what happens in other connections: you will have what makes for an inevitable clash of interests in the sense that a conservative proposal by one would be totally against the interests of some other member of the board who will want to act radically. In that way you would get a balance between excessive radicalism and conservatism.
In relation to appointments, I want to make sure, for example, that the officers of my Department are people deeply skilled in hospital and health administration: I think there are such persons. I have the very highest opinion of the officers of my Department. I have heard this view expressed by Deputies on all sides of the House. I believe three, four or five very good such officers can be appointed. They are practical men with a long record of experience. They have been helpful in devising new health services and they have shown a willingness to go ahead. There is an opportunity, obviously, for some other people with administrative experience, as suggested by Deputy Clinton. One might choose, for example, a number of chief executive officers who, if they have the same qualifications as Deputy Clinton no doubt attributed rightly to Mr. O'Keeffe, would have an understanding of medicine and of people. If one combines a group of people like that one should get satisfaction.
I have met enough consultants to know, as Deputy Dr. Browne knows, that there are consultants who know about administration. Some of the consultants who prepared the FitzGerald Report—like any other report it is not perfect but at least it shows great signs of progressive thought—were men of very considerable administrative ability. Therefore, one can find consultants with administrative ability. I do not think any 12 consultants or any 12 people appointed for any purpose related to a national operation could combine together to prevent something forward-looking being done if sufficient of their number were people with forward-looking views. If the consultants combine with some people well skilled in administration procedures such as chief executive officers and such as the fine officers of my Department I believe it will be workable. If it does not work we will have to alter the character of Comhairle na nOspidéal in an amending Bill but I have confidence that I can get the right kind of people for this purpose.
The Minister is digging a very big hole for himself and he will regret it but that is his business. However, this will not be in the interest of the improvement of our health services. I feel that the confidence he is placing in consultants is misplaced not on ideological grounds but on strictly technical grounds. The whole training, background and education of a doctor is very narrow and specific from the very beginning and it becomes more and more specific as he becomes a consultant. Therefore, the amount of useful knowledge which he will have which would help Comhairle na nOspidéal, which will have a very diverse function with very disparate outlets in relation to their responsibilities, will be very small. What in heaven's name would an ear, nose and throat man know about any other speciality? What use would he be if they were trying to decide on the setting up of an orthopaedic service? He would be little more use than an ambulance driver, a road worker or a builder's labourer. I feel there is a snob content in a Minister's approach to this. He was in two other Ministries—Lands and Transport and Power. He never brought into the House a proposal, for instance, that the number of CIE engine drivers or bus drivers on the board of CIE should be not less than half, or forestry workers when he was in Lands. He really is attaching to the consultant an authority, a power and a disinterestedness which he has not got, on average. There are some who have. For that reason this is a backward step both from the practical and the ideological point of view.
Why is this sector of society—the medical profession—chosen from all other sectors of society to be given control of a body in which they have a very direct and very important financial interest? It is wrong for the Minister to do this. He is suggesting that if one gets an ear, nose and throat man, a geriatrician, a paediatrician, a psychiatrist and a surgeon around a table they will start agreeing with each other. He knows this is not true. When we were trying to get a decision in relation to building a big regional hospital the person who eventually made the decision was the reverend mother because they could not get any agreement among themselves. There will be a continuous conflict not only among the consultants but between the consultants and the other members of the board and it will be a continuous squabble.
I believe the basis of the Minister's choice is wrong. I believe the decision to take it in a practical sense will also prove itself to be wrong. I am not concerned to knock the consultants. That is not my function nor my intention. I am simply concerned to see that this very important body functions well and properly in the interests of the community, not in the interests of a small sector of the community which, I believe, will benefit under this proposal of the Minister.
I am praying that some grammarian will say that it is all right to say "Comhairle na h-Ospidéal" instead of Comhairle na nOspidéal. Every time I say it I feel I am stuttering, a facility I had in infancy. In fact, at one time I was in a class for stutterers.
We must consider the present practice under which consultants are appointed. The truth is that consultants have an immense and almost limitless scope at the moment in relation to appointments of other consultants subject of course to ad hoc boards which are established. The Minister today said that unofficial influence is sometimes greater than the statutory influence. The unofficial influence of existing consultants is, of course, immense. Therefore, I suppose it is wise to endeavour to obtain their goodwill in the establishment of new boards. At the same time, I agree with those who feel that there should not be a preponderance of consultants on the new board because if that occurs we will lose some of the great value that we have in the present system.
I would ask the Minister to concern himself regarding the disadvantage and, indeed, the dangers that could arise if appointments are to be made by known personnel of a permanent board. At present various boards are set up for the purpose of making appointments and the practice is frequently to bring in outside experts, assessors from abroad, and people who are not known in advance. I do not know whether it is proposed that the new Comhairle na nOspidéal is to make all the appointments and all the selections or whether it will be open to the Comhairle to appoint a board.
When the regulations come before the House at a much later date, they will certainly include outside people.
That will help, but it is essential that each selection is made by a group the composition of which is not known in advance.
As far as possible.
It is also most desirable that there should be outside assessors to advise. If this is done a great deal will have been achieved.
I wonder would the Minister consider amending subsection (1) (c) to read: "but not more than half of the persons should be registered consultants". The fear is that three-quarters or a preponderance would be consultants. As long as half are consultants their interest and their special knowledge and experience will be available and the balance can be made up of people experienced in the other fields of medicine.
Is the amendment withdrawn?
Deputies
No. Vótáil.
The vote can be taken after questions.
Would it not be convenient now? It is ten seconds to 2.30 p.m.
The Ceann Comhairle has put the question.
Progress reported; Committee to sit again.