The basis of this Adjournment debate is a number of questions put down by Deputy Dr. Noel Browne over the past few weeks relative to the school health service and specifically the question I asked the Minister on 5th February. I wish to quote from column 255, Vol. 244, of the Official Report of 5th February 1970:
Adjournment Debate: School Medical Examinations.
Is the Minister saying that over an average school child's career in the primary schools he is given a comprehensive medical examination on three occasions?
Each child on average should receive about three examinations.
And the Minister is saying that this, in fact, occurs for every Irish primary school child?
Not every child. These are averages.
The reason for seeking some further discussions on this is the possibility which exists under the present system that a child can go through his entire primary school career without receiving any medical examination. The Minister will say in reply that he recognises the defects that exist and that plans are there for a revised and new service, and he can quote from this child health services report, the report of a study group appointed by the Minister for Health in 1967, and say he recognises the omissions from the service. However, the point that would be made by Deputy Dr. Browne, by other medical Deputies in the Labour Party and myself would be that we have known of the existence of this problem, whereby many of our school children have not been looked after in health matters for a number of years now and that plans at this stage are not that convincing in view of the lack of progress over the years.
There was ample legislative institutional arrangements made under the 1947 Act to ensure that our school children were given a proper medical examination during their school careers. Therefore, the achievement since that date would be this 1967 study group and now the Minister's ideas for an improvement in the position in the middle 1970's. We have made the point that the health of this part of our population is of tremendous importance to the future of this country. There are 300,000 pre-school children and 500,000 national school children in the State, a total of 800,000 children. The arrangements for seeing that these children are given a proper medical screening are totally inadequate. Despite the Minister's plans the figures show that in the last few years, even under existing arrangements, there has been a deterioration in the service. In answer to those questions of ours we have been told that there has been a decline in the number of children examined in the last three years: in 1966 it was 146,188 and in 1968 it was 128,447.
The number of schools taking part in the school medical service show an alarming decline. As I say, we do not know, and the Minister himself does not know, under the present arrangement exactly how many children are missing or have not been given an adequate medical examination. The figures suggest an alarming situation, and one which calls for immediate action. Even if there are plans in stock, and even if this is a very excellent report of the child health services here, the fact is that the existing situation is so bad that some interim arrangement is called for.
You cannot talk about the health of school-going children without understanding some of the background factors which go to undermine the health of certain children, for example, children from the lower income section of the population. Unfortunately, the position is that this is the section which more than likely escapes any medical examination at all. You have a very genuine problem here because the parents' permission is needed before the child can be examined. This is the parents' right and a great deal of work will need to be done to ensure that the child who may be in the most need avails of the service. This may be a child of parents whose experience of medical treatment has been one marked by a means test and so on. Such a child may be the one who tells his teacher that he does not wish to go for the examination. In fact, paradoxically, under the present system the child who comes from a home which can afford medical examination and get adequate medical treatment is the child in most cases who is ready to go for the school check.
Here is a genuine problem. I do not know what the answer is. Probably a great deal more will need to be done by parents' groups attached to schools and the various churches but there is a really big job to be done here, to persuade parents of the necessity for seeing that their children go for medical examination at school. Then there is the matter of the child who is missing on the day of the examination so there will be no examination for him or her, or the child in whom is discovered a serious ailment. The battle there is whether further treatment of that ailment is free or whether, in fact, it could be subject to a means test. There is certain disagreement about that. My interpretation would be that the further treatment should be free but there has been certain disagreement in that situation.
Now, of course, the state of our school buildings must be taken into consideration. We talk about poor home conditions, poor housing conditions, overcrowded conditions which exist in so many places here in Dublin, but the state of our school buildings is such that it cannot give any ground for complacency. It seems a bit ironic to hold a school medical examination in a school building which may be over 100 years old.
The state of our school buildings is not relevant. It does not relevantly arise.
I am talking about the health of our children and I am making the point that the state of our school buildings will have an effect on the pupils attending those schools. It would be ironic to think of bringing in improved health services to deal with school children in badly-built, Victorian schools. This in too many cases is true throughout the country. Many of the schools are old and ancient.
The Minister for Health is not responsible for schools.
The main proposal of the child health service survey was that we should have a scheduled medical examination at the age of six months, one year and two years. This of course would call for a vastly expanded health service. In fact, one might say that seems to be a part of the health service but its importance is not sufficiently recognised. This service is understaffed at present and not given a great deal of recognition. It is not given many facilities for training child specialists. There are child specialists for the better-off sections of the population but there are evidently no child specialists in the service to whom people in the lower income group could go.
Under the present situation for example—it is as alarming as this, as I found out from speaking to teachers— a serious heart case was missed; a child who was a victim of rheumatic fever and who later developed a serious heart ailment was missed in an examination. The Minister in reply to questions last week admitted that the frequency of the present examination gave no indication of its efficiency. I agree with that because even if there is a reduction in the number of children examined, we cannot for one moment imagine that under present arrangements a comprehensive examination can be given to any child. Even in the case of a child who has been examined it may be that since the facilities are not available for a really comprehensive examination a serious ailment may in fact be missed.
The most serious charge in regard to the present situation is the number of children not examined at all. The personnel of the school medical service are doing the utmost they can. All credit is due to those taking part in it, the nurses and doctors, but they are fighting against tremendous odds. Many of our school buildings have no particular room for the examination and in particular cases the principal's room must be obtained for the examination. For example, a medical examination which would demand an eyesight test, where the child would have to stand back a certain distance when an object is viewed, cannot take place because those conditions cannot be met in certain schools throughout the country.
I have been told by teachers in the city that there are tremendous inadequacies but they say also that a very serious problem is that of slow learners in the schools. Their point is that such pupils are not at present adequately catered for. We know there is a tremendous shortage of teaching accommodation facilities for the mentally-handicapped children but there are other children described as slow learners for whom at present there are no teaching facilities. Those slow learners require small classes, expert tuition and so on. In Dublin at present, in Orwell Road and the other centres, there is a long waiting list for appointment before such children can be examined under that category. Again, such problems should be part of an adequate and comprehensive school medical service.
We are left with the position at present where the school medical service cannot ensure adequately that our children have either sound teeth, good eyesight, hear properly or, still less, deal with any psychological disorder. It was admitted a year ago that the Department of Education have only a handful of educational psychologists attached to the Department. We can see, therefore, that the arrangements for the health of school children are primitive. The Minister, in the Department of Health, has formidable problems in many areas. In this area he has a really superhuman job to do which could take all his time over the next year or two. The Department of Health have a number of priorities. This matter calls for a very high priority indeed.
How long have I got to reply?
Ten minutes.
How long have I got to continue?
The Deputy has four more minutes.
Socialist nonsense.
I do not mind if the Minister would clear up some of the nonsense. The Minister could look at the school meals service. It could be improved. While it is associated with a means test system it will not generally be availed of.
The question relates to health services.
I have no responsibility for the school meals service. I will not reply to a general debate on this.
The trouble about health is that one cannot get departmental responsibility for it.
I am not going to take ten minutes to reply to a general debate on health.
There are many places where the Minister can speak throughout the country on this matter. He is not short of time. The Minister must, in fact, without any delay, consult with the various local authorities on the problems in their areas. He must consult with the teachers' organisations on the inadequacies of the present system. There is no time to be lost. It is fair to say that the Minister has attempted to remedy the situation with ambitious plans scheduled for the middle seventies. Something more is called for. We have not the assurance at present that our school-going population at primary level are properly looked after with regard to health examinations. A child can go through his whole school career without having a complete medical examination. This is a serious situation and one which calls for intervention by the Minister with the authorities concerned as rapidly as possible. There is a great deal of goodwill in the INTO which is the body I am specifically concerned with. They are anxious to say what are the disadvantages of the present situation. The Minister replying here two weeks ago spoke about the necessity of employing more people on the medical side of the services. This should be looked at as quickly as possible. I will now give three minutes to the Minister.
I want to reject the sort of socialist talk that I have, somehow or other, to take over the present child health examination service and the school examination service as though nothing was being done on them. The process of health service development is a continuous one. An enormous amount is being done to improve health services in this country. Deputy O'Leary can look at any statistic of the WHO and see that with all our defects and with all the improvements we have yet to make and with all the gaps in our health services, we are among ten or 15 top nations in regard to the health of our people. Let there be no nonsense as though I was talking about some hopelessly deficient service for children or for anyone else. The school health examination, although we believe it should be improved, is doing splendidly. Reference is made in the child health service report to the fact that out of every 1,000 children examined it was possible to ascertain that 223 of them should be referred for specialist investigation or treatment which is completely free. In respect of 27 children observed for the first time at school medical examinations it was found that they were being treated outside the school health service, showing the value of this service. Out of every 1,000 children 58 were discovered at a previous health examination and were receiving treatment. There was a miscellaneous group of 272 for reference to general practitioners or for observation with no need to do anything at the time of the examination. This showed that the school health examination, although it will be improved, is far from being imperfect and is doing an excellent job.
Deputy O'Leary mentioned that there had been a reduction in the school health examinations in 1968 as compared with 1967. That is true. In the case of some three counties there were deficiencies in staff which accounted for part of that reduction. There was a deliberate effort in Dublin in connection with the school health service to be more selective in advance of the new programme of which I sent a copy to all Deputies and Senators. I made it clear that the first priority I had chosen as Minister for Health was the improvement of the child health service and health service of all kinds available to children. That will take time and will require special courses of training this year and possibly next year for all the doctors involved at school medical examinations. It will require special courses of training for general practitioners who will have to take part in the child examination if the whole programme is to be effective in the course of four years. It will mean the appointment of more assistant medical officers. We are examining grades, the form of training required, and any changes necessary in the kind of degree or diploma obtained at the university in order to make this a more attractive service so that it will attract doctors into it who will feel they have a good career before them with possibilities of promotion. All that is being examined.
When the regional health boards are formed covering larger areas it should be possible to give more scope and greater opportunities for a good career to people working in a larger health area whose sole concern would be looking after the interests of children. We must build up the public nursing services all over the country. They are nearly complete. We must be certain that public health nurses have all the special training necessary for this work. I agree with Deputy O'Leary that the biggest job we have is to get far more collaboration between the parents, the teachers, the doctors and the nurses. They have all got to collaborate for the simple reason that we know that defects are discovered far more often in parent-accompanied children than in children not accompanied by their parents. About 50 per cent more defects are discovered when the parents are with the children. This means developing a new type of form which we will send to parents. The public nurses will have to help many of them to complete these forms. There must be propaganda to persuade parents to come with the children. In Donegal 84 per cent of the children are accompanied by parents compared with 25 per cent, 20 per cent, 17 per cent and 11 per cent in other counties. We will ask the teachers to collaborate and we will teach them to look out for certain types of defects. I am not particularly keen on a number of school health examinations.
As the Deputy knows, I have already taken the advice of the experts and the officers of my Department that we should have four pre-school examinations and we hope to discover and eliminate any defects that are now only being discovered in school. Then we hope to have one comprehensive examination at the start of a school child's life. After that, we shall not worry about the second and third examinations being complete examinations. We hope for far more selective examination. If we can get the child from birth to possess a medical card on which its health record is fully indicated and it can be known to the child's practitioner and to the public nurse, by the time the child reaches school we shall already know the medical and the mental background of that child. That will help us to ensure a far better and more comprehensive school examination.
It is quite evident that we must improve the service. I agree with Deputy O'Leary that the conclusions on the school health service in the report of the study group indicated there were defects. There are other defects in the health service. There were defects ten years ago which were corrected in whole or in part and as long as we go on we shall find that we have to make changes for the better in the scope and character of services. I think that when the volume of health expenditure, after eliminating the effects of increased wages and salaries, is doubled in a period of ten years compared with a corresponding increase of 50 per cent in the total volume of production, at least it shows that we are making a very big effort. That effort has shown itself, as I have said, in the actual statistics for deaths at all ages and in the statistics for infantile mortality. I am not content with those figures yet: I want to see us in the position where we can prove we have the highest standard of health in the world. We must yet make a very great effort. The seven conclusions of the school health service study have been noted by the Department and my plans for the next four years cover the removal of every single defect mentioned in this report.
We shall have difficulties. It will be difficult to get the necessary staff. Any campaign for improvement of the child health service involves many people, parents, nurses, doctors, county medical staffs and teachers and it will take us all our time to be able to complete the programme so that four years from now we can say that it is fully in operation.
What we are doing is bettering a service that has been extraordinarily valuable, a service that is far from being defective in the literal sense, a service that has done an enormous amount of good and has resulted in thousands of children being adequately treated. There is no correspondence in my Department from any Deputy or Senator or from any health authority to show that any child missed a health examination. It is possible that some child did miss an examination through being absent due to illness or some other cause when the examination took place and that the child's parents did not bother to ask for an examination when the next examination came around. Mistakes of that kind are always possible. We get enough parliamentary questions on every conceivable subject—that kind of communication is well established—to suppose that if there had been any remarkable number of children who failed to get a health examination it would surely be recorded in answer to parliamentary questions or complaints of one kind or another. Deputy O'Leary can be assured that is not so.
That some of the children in various areas were not given sufficient examination, I admit. That came out in this report. The cure is to ensure a better pre-school examination so that there can be a better and more selective school examination later and that the child's medical history will be known up to that point.
The Dáil adjourned at 5.35 p.m. until 3 p.m. on Tuesday, 24th February, 1970.