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Dáil Éireann debate -
Wednesday, 8 Apr 1970

Vol. 245 No. 6

Committee on Finance. - Vote 48: Health.

I move:

That a sum not exceeding £37,921,000 be granted to defray the charge which will come in course of payment during the year ending on 31st day of March, 1971, for the salaries and expenses of the Office of the Minister for Health, including Oifig an Árd-Chlaraitheora, and certain Services administered by that Office, including grants to local authorities, miscellaneous grants and certain grants-in-aid.

On the purely financial side, Deputies will be mainly concerned with subhead G which is the main subhead of my Department's Vote. It provides for grants to health authorities in respect of expenditure on health services. These grants comprise the statutory grant of 50 per cent, a supplementary grant, averaging about 6 per cent, and a new form of grant introduced for the first time this year, specifically related directly to the relief of rates. The total provision under the subhead is £32,908,000 which is £4,412,000 more than the latest figure for 1969-70.

The new special grant to which I have referred for the relief of rates accounts for £2,500,000 of the increase in the provision under the subhead as compared with last year. As Deputies are aware, there has been considerable pressure in recent years from ratepayers and rating authorities to have a greater share of health costs met by the Exchequer. Notwithstanding the many competing demands on the Exchequer, the Government, mindful of the fact that many ratepayers, particularly those on small incomes or on incomes which do not keep pace with increasing costs, are finding it a hardship to meet rates demands, decided that a special provision should be made available to enable increase in health rates to be contained within a reasonable limit.

Having considered various methods of distributing the £2½ million, I decided that in the interests of the majority of ratepayers allocations should be such as to equalise the increase in the health rate throughout the country. The substantial amount made available was sufficient to limit health rates increases to 2s in the £ and allocations of special grant were made to health authorities to achieve this objective. These allocations were determined on the basis of information received by my Department from local authorities, prior to the announcement of the new measure, as to the health rate likely to be required in 1970-71 if health grants remained at the same percentages as in 1969-70. The allocations varied from area to area depending on the anticipated rates situation for 1970-71. I should emphasise that but for this special assistance, increases in health rates would have ranged up to about 12s in the £.

Taking account of the special grant, the cost of health services in 1970-71 will be met to the extent of about 60 per cent from the Vote for my Department. If the relief afforded by the agricultural grant is taken into consideration, the total Exchequer contribution towards expenditure on health services in 1970-71 will be equivalent to about 76 per cent. I think Deputies will agree that this represents a generous sharing by the Exchequer of the cost of health services and will welcome the additional assistance for the relief of rates which is provided for in the Estimate.

The total net health expenditure by health authorities, which will be shared by the rating authorities and my Department's Vote on the basis which I have described, is estimated at £55,385,000 for 1970-71. This is £3,185,000 in excess of the latest figure for 1969-70. It is estimated that about 70 per cent of the increase relates to improvements in the volume or quality of services.

The main factors responsible for the increases are as follows: increase in capitation rates payable by health authorities for services in voluntary hospitals which account for £650,000; additional bed accommodation, particularly in the new St. Vincent's Hospital, Elm Park, which will take £390,000; improvements in standards in general hospitals run by health authorities, including extra medical and nursing staffs, improved casualty services and ambulance services, an additional £390,000; £400,000 for improvements in standards of treatment and accommodation in mental hospitals; additional places in residential and day care units for mentally handicapped persons and improved standards in county homes which will cost £325,000; increased issues of medicines at dispensaries costing £250,000; an extra four months operation, in 1970-71 as compared with 1969-70, of the increased rates of allowances for disabled persons and persons suffering from infectious diseases approved with effect from 1st August, 1969, which will require £200,000; and improvements in maternity and child health services estimated to cost £130,000. A provision of £435,000 is included for price increases.

Subheads K.1 and K.2 of the Vote provide for grants-in-aid to the hospitals Trust Fund—£3,200,000 under subhead K.1 related to the revenue deficits of the voluntary hospitals and £1 million under subhead K.2 in respect of capital expenditure. These grants are required because there are now no reserves in the Hospitals Trust Fund and the current income of the fund from sweepstakes is not sufficient to meet commitments by way of capital grants, grants to cover the revenue deficits of voluntary hospitals and miscellaneous grants.

The amount sought under subhead K.2 is, at £1 million, the same as for last year. The requirements under subhead K.1 show an increase of £450,000 despite the adjustment as from 1st April last in capitation rates payable for services provided in voluntary hospitals. The increase arises mainly from adjustments of pay and improved conditions for staffs employed in these hospitals and increases in prices.

There has been an enormous increase in expenditure on health services in the last decade. Taking account of both revenue and capital expenditure and grants from the Hospitals Trust Fund in respect of the revenue deficits of voluntary hospitals, the cost has risen from about £18½ million in 1958-59 to about £61 million in 1969-70. Increases in salaries and wages and price increases account for a very large part of this increase. However, even if these factors were eliminated, the increase in real terms of the allocation of financial resources towards betterment in the standard and scale of health services has been enormous. In fact, the volume cost of health services after eliminating increases in unit costs has doubled in the period between 1958 and 1969 during which the volume of production rose in real terms by some 60 per cent, illustrating successive Governments' decisions to make use of national resources far beyond the cold-blooded norm in order to improve health services.

Subhead Q is a new subhead in which a token sum of £100 is provided to enable my Department to meet expenses incurred in the recruitment, training and payment of chief executive officers for the new health boards and the travelling expenses of members appointed to these boards in the current financial year until full responsibility is transferred to them on 1st April, 1971. It is not possible to estimate with any degree of precision what the cost is likely to be and accordingly at this stage I am asking for a token sum. The full amount of these costs in the current year will be a final charge on the Exchequer—in other words I am not proposing that rating authorities should bear any of it.

Having just referred to the initial financial arrangements being made in connection with the implementation of the Health Act, 1970, I feel that I should inform the House about the progress being made towards effecting the main changes under the Act before proceeding to a more detailed analysis of the services.

I am obliged under the terms of the Act to consult the relevant local authorities about the regulations on the consultation and functional areas of the new health boards. I have now sent draft regulations to them for any views they may wish to offer. The draft regulations which I will submit to the Oireachtas for approval before making them will take account of any views put forward by the local authorities. My present intention, which is in accordance with what I said during the debates on the Bill, is to establish the health boards on 1st October next and to transfer to them responsibility for the operation of the health services as and from 1st April, 1971. I expect to have the draft regulations before the House some time next month.

The House will then have an opportunity to debate the resolutions setting up health boards, regional hospital boards and Comhairle na nOspidéal when they come before the Oireachtas —I have already given a general description of these bodies.

The staffing aspect of the new authorities is an important one. I expect that the Local Appointments Commission will be in a position to invite applications for the posts of chief executive officer within the next few weeks. As regards the present staffs of health authorities, I am very conscious of the fact that they are concerned about the implications for them of the pending changes. I am most anxious that none should have a justifiable grievance as a result of the reorganisation which will be necessary and I am now in the process of setting up a joint consultative council to smooth the transfer of staffs. This council, which will include representation from the staffs concerned, will advise me as to the arrangements for the transfers, and will assist me generally in ensuring that the interests of all are adequately protected. Management advice will be available to the health boards so that their role can be effective and to enable them to delegate to the chief executive officers various functions of day-to-day management.

As the House is aware, the new Act provides for the abolition of the dispensary service. I hope to be in a position on 1st April, 1971, to replace it with the proposed choice of doctor scheme. After that date, the office of district medical officer will cease to exist but all serving permanent officers and many of the temporary holders of these posts will have automatic right of entry to the new scheme. It will still be necessary in some areas, in particular, in the remoter and more sparsely populated parts of the country, to appoint doctors on a salaried basis to ensure that the local people have a convenient service. I am most anxious to ensure that the people in remote areas should have no worries in this regard and it is a matter which will receive my special attention.

I am not, however, yet in a position to report agreement with the medical profession on the terms on which general practitioners will participate in the new scheme. I can say, though, that negotiations with them are proceeding in an amicable atmosphere and that I expect to bring them to a satisfactory conclusion within a reasonable period. I think that Deputies will agree that it would not be inappropriate for me at this point in time to put on the record of this House my tribute to the very effective service provided over the years by the dispensary medical officers.

Discussions with the retail pharmacists, who, it is hoped, will also participate in the scheme, are continuing. A difficulty here is to arrive now at agreement on a level of payment which would be reasonable in relation to prices and remuneration prevailing at the commencement of the scheme, one year from now. However, when the impact of the present round of wage increases becomes clearer in a few months time, I expect that it will be possible to agree terms with the pharmacists.

I might mention that the participation of retail pharmacists in the general medical services will involve a major administrative task, the checking and pricing annually of millions of prescriptions issued to eligible patients. Fortunately, it has been shown elsewhere that a task of that nature can be done efficiently and economically by computer. We are planning a similar arrangement here—and I should like to avail myself of this opportunity to acknowledge publicly the assistance given, and being given to my officers in planning our service by the Ministry for Finance and the Ministry for Health and Social Services in Belfast as well as the Northern Ireland General Health Services Board.

These are some of the major changes which we will see under the new Health Act. Work is also proceeding on schedule on the other changes proposed and we are working to the timetable which I outlined at the conclusion of the debate on the Bill in February last.

With the statistical information I supplied to Deputies, I included some vital statistics and comparative expectation of life figures. In broad terms I think these statistics show that we now hold our own with most countries, that we are a reasonably healthy nation and that we have reasonably effective health services.

In regard to expectation of life, maternal mortality, infant mortality and the general death rate we are among the top ten nations.

There are no statistics for the percentage of the population in good health or the percentage of persons delaying treatment because of ignorance or prejudice. There are statistics indicating that the child health services to which I refer later, need to be stepped up to discover and remedy, as early as possible, physical and mental defects. I am convinced that over the next years, we shall have to establish health education services on a more extensive scale.

In common with other countries we are being hit hardest in mortality figures by the new killers of the affluent society namely, heart diseases and lung cancer, and although in both these cases the provisional figures for 1969 show a welcome down-turn as compared with 1968, the position in respect of them leaves very little room for complacency. We can, I suppose, only continue to urge on people the adoption in their own interest of a healthy regimen of life by every means at their disposal. I would have thought in this regard that the public would have paid greater heed to the constant warnings by a variety of health agencies, outside as well as inside this country, of the folly of eating, drinking and smoking too much and not taking enough exercise, but I suppose that the death figures I have mentioned in a curious way reflects the eternal and so often tragically misguided optimism of the human species expressed in the phrase "it will never happen to me". All that a Minister for Health can do in this situation is to continue and, where possible, intensify the health education programme which, assisted by such voluntary agencies as the Irish Heart Foundation, the National Council on Alcoholism and the Irish Cancer Society, is beamed at the public.

I have thought it well to include with the mortality statistics circulated a table of deaths from accidents in the home. At 450 in 1968 the number of such deaths exceeded by 20 the number of persons killed in road accidents in that year. Two hundred and sixty-seven of these deaths in the home occurred in persons aged 65 years or more. As the recently published Report on the Care of the Aged made clear, the elderly, because of failing senses, are particularly vulnerable to accidents in the home and they are, of course, likely to be affected more seriously by such accidents. The more common types of accidents to which the elderly are prone are falls, burns and scalds and gas poisoning. We are, and will be, concentrating publicity on the hazards which the home can present.

During the past decade considerable advances have been made in regard to infectious diseases such as tuberculosis, poliomyelitis and diphtheria. There has been a continuous decline in the number of new cases of T.B. and in the number of deaths from the disease. For example, 4,004 new cases were registered in 1959, whereas the number registered in 1968 was 1,684. Deaths from the respiratory from of the disease dropped from 502 in 1958 to 225 in 1969. Poliomyelitis, diphtheria and typhoid have been reduced, as public health hazards, to manageable proportions.

Unfortunately, the position as regards venereal disease is not quite so happy. In 1968, there were 99 reported new cases of syphilis as against 24 in 1967 and 23 in 1966, while the number of new cases of gonorrhoea in 1968 was 383 as against 247 in 1967 and 207 in 1966. I have asked my Department to keep a close watch on the situation and, in particular, to ascertain as speedily as possible the 1969 figures. If these figures show a continuation of the upward trend then I will set in motion arrangements to have a study made designed to examine all the factors involved in the increased incidence including the socio-economic levels of those contracting these diseases with, of course, all due regard for medical secrecy. From such a study it might be possible to take measures which would control the incidence of these most serious maladies—most serious not only for the individuals concerned but because of the potential they have for infecting others. Indeed, on this particular point I have begun to speculate as to whether there should be penalties in the law to back the protection of the public health. I do not at this juncture wish to take my speculation further, except, perhaps, to add that we take steps to take a known carrier of infectious diseases out of the food business so that the public may be protected.

I have circulated to the Deputies detailed statistics of the local authority hospitals for 1968. These give some idea of the volume of work being performed in these hospitals and the cost involved. It is of interest to note, for example, that the cost of treating one patient in a county hospital averages about £30 a week, or £46 for the full course of treatment in hospital. As might be expected, costs in the major teaching hospitals are considerably higher, being on average up to £38 a week, or £73 for the treatment of one patient for the duration of his stay.

One note of warning which I would like to sound in the interpretation of these figures is that indiscriminate comparisons of the figures for individual hospitals may give misleading results. For example, in two hospitals which belong to the same general category, the type of patient treated in one may be completely different from that of another. It may be the practice in one hospital to admit a relatively large number of long-stay patients. This hospital would then experience a long duration of stay, a low cost per patient week, a high total cost per patient and probably a high rate of occupancy.

Present-day costings indicate the need for constant vigilance in ensuring that the hospitals are operated with maximum efficiency consistent with good medical practice. The hospital is now a large and complex organisation with many specialised components. It is staffed by people skilled in a variety of disciplines, many of whom have reached the peak of their profession. It contains equipment which is elaborate and expensive and which requires highly skilled operatives for its most effective use. Not only does it practise the many and varied techniques of diagnosis, prevention and cure of illness, but it must also play its part in the fields of education and research which are accepted as an essential element of the hospital scene. Over 300,000 patients a year, more than one in ten of our population, are treated in the acute hospitals in Ireland.

Before developing this theme further I think I should say that I do not accept unreservedly that development of medical services should be openended. Some limitation in cost is essential and new, complex and expensive techniques which are of marginal benefit from the public health view-point would have a low priority rating in an area of fierce competition for resources.

It is clear that, as the size and operating costs of hospitals can be equated with those of major industries, so also the need for efficiency of operation is as great as in the industrial sphere. Expert management and administration are essential features of an efficient organisation and, in our efforts to build up the clinical services, we may have tended in the past to play down the importance of good management. We must in the future give more careful attention to this aspect of the hospital organisation by the provision of suitable training at a high level of administration and the use of modern techniques, such as work study and operations research, as management aids. One aspect of the hospital service which will repay attention is "throughput" of hospital beds, or the number of patients treated per bed over a specified period. For a number of years we have been taking part in a world-wide phenomenon of an increasing demand for hospital treatment. The rate of increase in Ireland has been about 4 per cent per year. Expansion of this order makes it imperative that the available accommodation is used as effectively as possible. Bottlenecks and other factors causing unnecessary delay must be identified and eliminated.

I am setting up an organisation unit in my Department which will initiate work study, management study and other forms of examination into hospital administration. The object will be to increase efficiency which, in a labour-intensive organisation means ensuring that the staff do a useful and non-excessive quantum of work in the most effective manner. Such studies must take account of the human service element involved, but I wish to make it clear that neither capitation grants nor deficit payments will be given in future to hospitals, voluntary or local authority, who refuse to participate in such examinations after consultation. This is a final decision.

Capital expenditure on hospitals has to be related to the need to keep overall capital expenditure in the public sector within reasonable limits. That is not to say that it is not substantial During 1970-71 it is expected that £3.6 million will be spent on hospital building works of which £2.2 million will come from the Hospital Trust Fund, assisted by grant-in-aid of £1 million from the Exchequer, and £1.4 million from the Local Loans Fund and other sources.

The statement recently circulated to Deputies contains lists of the major hospital building projects completed during the past year, projects under construction as at March, 1970, and projects now at an advanced stage of planning on which building work is likely to be commenced during the year 1970 and 1971. Projects under construction at present and those on which building work is expected to start by 1971 will have a total estimated cost of approximately £15 million.

One of the most important projects is the new St. Vincent's Hospital at Elm Park, Donnybrook, Dublin, a major teaching hospital of 455 beds. This fine new hospital will replace the existing St. Vincent's Hospital at St. Stephen's Green, Dublin, and will also, if present plans are agreed with all the parties concerned, form the major part of the proposed regional hospital for South Dublin, as envisaged in the Report of the Consultative Council on the General Hospital Services, to which I will refer later in more detail. The first patients were admitted to the hospital during January, 1970. The total number of patients there at present is 54. The intention is to build up the bed occupancy during the coming year on a phased basis so that the hospital will be fully operational by the end of 1970. A nurses' home and training school and a school of radiography will be completed this summer. The total cost of the new hospital, including the nurses' home and training school, will be in the region of £4 million.

Other building projects in the general hospital field completed during the past year included a training school and staff home at St. John's Hospital, Limerick, new operating theatre, et cetera, at Barrington's Hospital, Limerick, and improvements at the Meath and Jervis Street Hospitals, Dublin. Projects in progress during the year included new operating theatres at the Mater Hospital, Dublin, and the Sheil Hospital, Ballyshannon, new nurses' homes at Temple Street, Dublin, and the North Infirmary, Cork, a new central laundry for Dublin hospitals and various improvements and extensions at a number of other hospitals.

The most important health authority general hospital scheme nearing completion is the 100-bed extension to Sligo County Hospital, to be commissioned this year. It will provide additional maternity beds, specialist facilities for ear, nose and throat and ophthalmic cases and paediatric care, new x-ray accommodation and an out-patients department, an extension of the pathology facilities and some accommodation for medical and nursing staff. Work will be commencing soon on a scheme to provide additional accommodation for 54 nursing staff at the hospital.

Among the more important health authority general hospital schemes now in planning are:—

the 600-bed Cork regional teaching hospital project and the 300-bed general hospital at Tralee.

The detailed schedules of accommodation have been settled for the Cork scheme. Planning is at present being concentrated on the production of economically conceived sketch plans so as to ensure that a scheme for a satisfactory hospital will evolve which can be built at a cost which can be met in the light of other demands on our resources. The Cork Hospitals Board expect that final planning will be completed in sufficient time to enable tenders to be invited by the end of next year.

Regarding the planning of a new general hospital at Tralee, this hospital will provide acute general medical and surgical services, obstetrical care and psychiatric and geriatric units to serve the Kerry area.

This brings me to the FitzGerald Report and, speaking of the examination necessary before evaluating finally the recommendations for nine general hospitals, as recorded in that report, I think I should be absolutely frank with the House in regard to my attitude. In the case of a number of the hospitals recommended, there is little or no controversy. I refer to the choice of Letter-Kenny, Sligo, Castlebar, Tralee and Drogheda as centres for five of the proposed general hospitals.

In the case of the hospitals outside Dublin, running in a line through what I might describe as the North Midlands to Waterford, there are already ample signs of tremendous agitation for the discussion of proposals, preparation of reports and requests for meetings with the various authorities concerned. The FitzGerald Report proposed, in addition to Drogheda, Cavan, Tullamore and Waterford as locations for the enlarged general hospitals. In the same general area there are county hospitals with 110 to 150 beds—in Monaghan, Dundalk, Navan, Mullingar, Portlaoise and Kilkenny. There is also a county hospital at Wexford, where the county council and other bodies have stressed the necessity for preserving surgical facilities there and, indeed, developing them, in contrast with the recommendation in the FitzGerald Report that the Ardkeen Hospital at Waterford should be developed to cover the Wexford area.

It will take some time for me to study in depth the proposals in the report for the location of the general hospitals in this area and to make final decisions regarding implementation or amendment, having regard to financial possibilities. At the same time may I say that I accept absolutely the conclusions in the FitzGerald Report on the changing character of medicine and surgery and the growth of specialities. The choice must be made eventually as to the sites for these large general hospitals. The Government have accepted the whole of the report in principle. I find I might say that the vast majority of up-to-date consultants fully support the general FitzGerald principles and my decision on the general policy to be followed is not subject to modification.

As I have already said on previous occasions, I will not be deterred from making a decision based on, firstly, ensuring that extremely expensive equipment is properly used; secondly, being able to offer specialised consultants, physicians and surgeons, positions of interest which will attract the best talent; thirdly, determining the choice on the basis of reducing mortality and equally reducing the length of stay in the expensive general hospital to the lowest number of days possible, this in turn being related to the possibility of using other smaller hospitals for convalescence, particularly where patients' relatives are some distance away from the general and regional hospitals. I have also agreed to meet local advisory committees set up under the Health Act before the decisions are made.

At this point I must make an absolutely definite statement reflecting the fact that I am realistic and that I absolutely refuse to indulge in politico-ministerial humbug. Whereas I will, of course, study the representations made to me for the use of this or that location for a general hospital centre, I have absolutely no doubt that, having read all the representations, no Minister on earth can make a decision on the basis of valuing the specific statements made by each local committee. There are arguable reasons for choosing the sites of the eastern general hospitals from a choice of hospitals including Monaghan, Dundalk, Cavan, Navan, Mullingar, Portlaoise, Tullamore, Kilkenny, Waterford or Wexford, or for providing more than the total number specified, namely, four.

Each of the policy statements made by a county council, a group or council representing a town, or a special ad hoc committee, will be in direct contradiction to the similar representations made by other such bodies; that is inevitable. The plea of Monaghan would be antagonistic to Cavan and favourable to Mullingar; the plea of Tullamore would be opposed to that of Portlaoise or Kilkenny, and so forth. All any Minister can do is extract from each representation whatever is really significant in studying the question as a whole. I might even decide to appoint a small independent committee to make the final recommendation to me.

It will be noted, however, that Comhairle na nOspidéal will have authority to decide on the types of consultants to be appointed to the general hospitals and their decisions will affect the issue. Any amendment to the plan will almost inevitably mean choosing sites for the hospitals south of this area at different places from those proposed in the FitzGerald Report. There are, quite clearly, borderline cases.

I wish to make it clear that I have got to be advised mainly by experts in the field of hospital development on this matter. I also wish to make it clear that I am not going to confuse the issue or make decisions any more difficult in considering locations for general hospitals covering this area, by reference to what is to be done in the area of the western regional and southern regional hospital boards where the decisions must relate to the areas concerned.

I now come to the question of hospitals where major surgery will cease to be practised as a result of the decisions above-mentioned. I, again, wish to be absolutely frank with the House so that they can see a perfectly clear picture of what is in my mind. First and foremost, I do not consider or believe that surgical facilities in a particular hospital can be taken in isolation in considering what might be described as the total availablty of health services in the immediate area of the counties surrounding a particular hospital and I am going to be absolutely firm on this matter.

So I now set out once again the present and future pattern of health services, distinguishing between policies involving decentralisation and centralisation. I make this distinction because, in my view, it is completely wrong to give such exaggerated importance to the surgical facilities in a hospital without considering the whole field of medical services in an area. I have told those who have made representations about maintaining surgical facilities at certain hospitals that I am concerned, firstly, with keeping people out of hospitals and, secondly, with ensuring for them the best possible attention when they have to go to hospital; attention which will involve the availability for their treatment, in many cases, of more than one consultant.

The services which result in decentralisation, i.e. medical care, health education and what I might describe as medico-social services to people are, in brief, as follows. I will, I should say, be describing some of them in more detail in later portions of my speech.

Firstly, we already have a policy, which will be expanded, for widening the scope of consultant diagnostic out-patient service by the larger health boards through the operations of the regional hospital boards so that more people in rural areas and in small towns will be able to see expert consultants on a variety of illnesses and conditions, the necessary equipment being made available. Consultant work will include psychiatric examinations. I must say I regard this as of just as much importance as doing any surgical work in a particular hospital.

Secondly, in many areas the choice of doctor system for those entitled to free general practitioner services will provide a more varied service and this again will mean a direct contribution towards what I might describe as decentralised medical services. If a number of general practitioners, whose training will inevitably be more specialised in the years to come, decide to set up in a large town and work together as a team, the same position will hold in so far as the area served by that town is concerned. There is the need for more associations by general practitioners with hospitals.

Thirdly, the development of the child health service. Pre-school children will receive at least three or four detailed examinations, not only in the child welfare clinics, where available, but in new clinics where they are desirable, or in the surgeries of general practitioners elsewhere. School children will have more detailed and selective school health examinations.

Fourthly, there will be a continuous expansion of domiciliary care, with the object of keeping people, particularly old people and psychiatric patients not seriously disturbed, out of institutions and at home as far as this is possible. For this purpose, there will be home helps, working as far as possible with voluntary organisations, together with social workers, public health and psychiatric nurses, and other personnel. There will be more visiting of mentally ill persons by psychiatric workers in their homes. There will be more day centres for old and psychiatrically ill persons. There will be experiments possibly in paying boarding-out fees for old people to provide company, for those who would like to look after them.

Fifthly, I expect the work of the public health nurses to expand and develop during the next few years. These nurses will engage in health education, which will also be done in the schools, apart from radio and television publicity. As the years go by, public health nurses will become, even more than they are at present, the friend of every family in an area.

Sixthly, the ambulance service will be standardised and radio-telephone controlled. Ambulances will be situated at desirable centres for the quick movement of patients and they will work over a larger area because of the creation of the health boards. Ambulances will be properly equipped. The road system will have improved still further by the time the replanning of hospital services will have had full effect.

Seventhly, there will be special seminars for general practitioners to enable them to keep abreast more than ever before, of modern developments.

Eightly, wherever it is possible and desirable, there will be places in smaller hospitals for those who are convalescent after having received acute care, particularly acute surgical care in a large hospital, for the period of which visits by relatives would not have been possible in any event.

Ninthly, even in the regional hospital board areas by themselves, an effort will be made to reduce the number of patients who have to go to Dublin for specialised surgery and treatment. This will be done by a careful evaluation of the kind of speciality that can be developed in the regional hospitals at Galway, Cork and, of course, Limerick and lesser specialities in the new general hospitals.

In connection with the work of the regional hospital centre and another. make it perfectly clear that costs can be saved, in both capital and current expenditure and, at the same time, lives can be saved and people can be restored to greater health with the inevitable change in the pattern of movement of patients as between one regional hospital boards, I wish to Comhairle na nOspidéal, in deciding on the type and number of consultants concerned, and myself, in providing the capital for the hospitals, have to take a realistic attitude. Patients may expect to have to move, in some cases, to new hospital centres in their own personal interest. This is happening all over the world and it will happen, too, here in Ireland. The concentration in centralising policy consists in ending surgery operations in single surgeon hospitals and in the inevitable development of specialist treatment at the regional and other fully staffed large hospitals.

I have also read statements from county councils and other interested bodies regarding the value to a town of surgical facilities in a hospital as a contribution to the expenditure in the town in terms of the surgical staff employed, with their ancillaries, and the expenditure by patients or by the local authority and by the people visiting the hospital. I want to make it absolutely clear that I can take no account whatever of such representations. If we are going to afford any of the future hospital development, it can only come by an increase in the gross national product and the development of industry, together with the maintenance of prosperity in the agricultural and tourist fields.

The towns where major surgical facilities may be ended over the next eight years will have benefited by industrial growth and the general prosperity of the country. Where a county hospital ceases to practice surgery, it is more than possible that the general practitioners will have a greater part in the use of the hospital and that patients will come to the town in order to attend out-patient diagnostic clinics. Hospital beds will be used for other purposes. This completely inapplicable argument has no significance. My decisions will be based on how to attract expert consultant staff to the hospital services of the country, to ensure more modern treatment so as to preserve life and ensure sound health, and, above all, all my efforts will be aimed at keeping people out of hospitals as far as possible and seeing that they stay in the more expensive hospitals for the shortest possible time.

I should also mention the inevitable implications of the Todd Report, which must be faced resolutely and realistically by all the organisations who are going to make pleas for the retention of surgical hospital facilities in various areas. The Todd Report makes it absolutely clear that the medical graduate of the future will be given a very clear indication of prospective openings in the various specialities required, and having made his choice in a speciality which can absorb him he will have an extended course of training in that speciality. This is going to lead to greater specialisation. At the same time, hospital equipment is becoming more expensive and para-medical services more complex in character. I am told by the experts that, within a certain number of years from now, a really competent surgeon with the kind of experience and technical ability required will not apply for a position as a surgeon in a single-surgeon hospital. I am told that the re-grading will be inevitable in respect of other staff in the hospital and that house surgeons and interns will more and more require varied experience and will more and more seek appointments to larger hospitals. I am told that in relation to the Todd Report there will be no place for a registrar in a single-surgeon hospital. Those who are concerned with the future development of good hospital services in this country must face up to this inevitable development of specialities. I counted thirty separate specialities the other day in the course of a review of the consultant position, including four separate specialities in respect of infants of under four years of age. I here quote portion of a report on future hospital development in Scotland, which is the country most like our own, with which one can make a comparison:

Lastly, the number and size of the clinical units which a major hospital contains, and the distribution of these units between the hospitals must be such as to permit an economical and effective distribution of the consultant staff, both those responsible for the clinical treatment and those in charge of the diagnostic and laboratory departments. There are considerations which weigh against individual consultants working in isolation without the stimulus of colleagues and without the facilities for the teamwork between different specialities which is now increasingly required in some advanced kinds of treatment. Smaller units, too, have difficulties in attracting junior medical staff because of the limited experience they can offer to young doctors in training and consultant staff cannot work effectively without supporting assistance.

The problem of the requirements of 300 bed hospitals for nurse training is always with us. In studying the FitzGerald Report there is also the possibility of a temporary compromise solution for a period of years by inducing the voluntary and local health authority hospitals in an area to integrate with each other or integrate with a regional hospital not too far from the hospitals concerned. One example would be the relationship of the Roscommon and Portiuncula Hospitals with Galway Regional Hospital, linkage in respect of out-patient diagnostic services and in-patient services.

Having made this detailed statement in regard to the FitzGerald Report I should make it clear that some time will elapse before I can make decisions on the future of individual smaller hospitals and those interests who either wish to preserve surgical facilities in a particular hospital or who wish to promote the case for the siting of a new general hospital do not need to continue with a spate of representations.

The proper course for me is to instruct Comhairle na nOspidéal on the time schedule for decisions they will be making in regard to the appointment of consultants, to so instruct the regional hospital boards that they can pursue the planning of a first-class hospital system in each area, having as a prime objective the greater integration of voluntary and health board hospitals. At the proper time I will consult the local committees set up under the Health Act, who can present to me the views of, sometimes conflicting, sometimes agreed, organisations or bodies. I will remind the House, finally, that under section 38 of the Health Act, 1970, I must hold a local inquiry before directing the discontinuance of a hospital, so that neither this nor any major change in the user of a local hospital will take place without full consultation.

Child welfare and school health services have been important features of the public health scene for many years. The child welfare service has, in the clinics, provided a medical examination service for young children and a source of advice and help for their mothers. The school health examination service has in general provided three medical examinations for national school children during their school life. To give Deputies an idea of the scope of the present service, I should say that in 1968, 130,261 children or 26.2 per cent of the children on the rolls of national schools were examined. The service has been responsible for the detection and treatment of defects in many children which might otherwise have gone unnoticed. The many medical officers who, throughout the years, have provided this essential service have served the community well and I am glad to have this opportunity of paying tribute to their work. As Deputies will know, the scope and nature of these services was examined by a specially appointed study group.

It had, of course, been clear that the restriction of the pre-school examination service to urban areas was a considerable limitation on its scope since it reached slightly less than half of the total number of pre-school children. So far as the school health examination was concerned the group drew attention to the fact that the examination of large numbers of healthy children was an obstacle to the fuller examination of children needing particular care and attention. These two considerations were at the root of the many recommendations made by the group which I have accepted.

I have indicated that I propose to introduce the new service gradually over a period of four years, commencing in October next. The ultimate objective is to provide a comprehensive medical examination for children at the ages of six months, 12 months and two years in clinics in the major towns. Routine medical examinations in national schools for new entrants will be replaced by comprehensive medical examinations for children over six years shortly after they commence school. Selected groups of these children will be given further medical examination as required throughout their national school life. By next October special training in developmental paediatrics will have been provided for assistant chief medical officers participating in the revised services, and in fact already about half of these doctors have received such training. I should also mention that a working group is being established to produce a standard record card which would be used throughout the child's participation in the child health services.

The pre-school development paediatric examinations in rural areas will be provided by general practitioners as soon as practicable. These examinations will be similar to the examinations provided by assistant chief medical officers in the clinic premises in the larger urban areas. The areas in which the general practitioner examination service will operate and the extent to which general practitioners will require suitable courses in developmental paediatrics are matters which will have to be discussed later this year with the appropriate professional organisations.

The success of the new services for children will depend in no small measure on the degree of co-operation and involvement of the people most in contact with the children. Parents, teachers, public health nurses and school doctors must pool their knowledge and experience of the child, to ensure that he will obtain the greatest benefit from the services being provided. All this involves a public relations campaign and far more emphasis on health education.

In the recently published report on the care of the aged, a copy of which I circulated to each Deputy, great stress is laid on the need to develop community services in the belief, as I have said earlier, that it is much better to help the aged to live in the community than to provide for them in institutions. The important role being filled and to be filled in future by voluntary organisations was emphasised. My Department accepting that view fully, expanded further in 1969-70 the scheme of grants to voluntary bodies engaged in the community care of the aged. The health authorities were authorised to give grants totalling £75,000 to voluntary bodies performing worthwhile social work for old people in the community. The Department have encouraged them to make full use of the scheme in order to boost voluntary effort and each authority has full discretion to make grants, within the financial limits of the scheme, without seeking my specific sanction in each instance.

The wide range of activities being supported includes clubs and recreation centres for old people, occupational therapy, chiropody, social worker services, meals on wheels, reading and television rooms, social evenings and outings, home repairs and renovations. A major assessment of the services for the aged provided by grant-aided voluntary bodies is at present being undertaken by my Department. The aim of the assessment is to identify more clearly the type of community services for the aged which should be given priority and the areas of the country where greater voluntary effort needs to be stimulated. I intend subsequently to issue guidelines to health authorities which would assist them in getting the best return in terms of the aged for the grants available.

In the current financial year the authorised level of these grants has been increased to £100,000. When it is realised that the equivalent level of grants only two years ago was £12,000, the readiness of the Government to step up their commitment to voluntary bodies looking after old people in the community can be readily appreciated.

While the first consideration should be to develop the community care services to the maximum extent possible it will, of course, be essential to continue to provide effective institutional services. As I see it, the cornerstone here would be assessment and diagnostic centres established on a countrywide basis to which patients for whom long-stay institutional care is felt to be necessary would be referred in the first instance. In such centres the individual patient's specific needs would be determined and he or she would be referred to appropriate medical, intensive rehabilitation or long-stay accommodation as the case might require.

The time required for bringing into full effect over the country as a whole such a concept of institutional services for the aged must necessarily be fairly long. Some of the organisational changes necessary will be affected by the decisions to be taken on the pattern for hospital and specialist services in the future. It will also be appreciated that there is no single blue-print on which the organisation of institutional services might be based. The question of utilising all the services available, whether at regional centres or county or district hospitals or voluntary hospitals, will have to be considered. Variations to suit local conditions or population concentrations will be necessary. For example, in areas of heavy concentrations of population the organisation of day-hospitals and efficient domiciliary services would considerably ease the strain on the institutional services. Furthermore, the institutional services cannot be planned in isolation. There must be effective co-ordination of all services designed to cater for the aged from housing to hospitals and of all the agencies, whether health or local authority or voluntary agency that play a part.

During the last decade considerable progress has been made in the development of improved institutional services for the care of the aged. We have been proceeding on the basis that in each county there should be developed units to serve as long-stay hospitals. The new nursing units which have been built are geared by modern standards to provide for the care of the chronic sick. Accommodation is also being made available in which physiotherapy and occupational therapy services can be provided. Where feasible, some of the units are being located on the sites of county hospitals or in as close association with them as possible. Good accommodation which was surplus to other requirements has also been availed of as in the case of St. Mary's Hospital, Phoenix Park, Dublin, some units at James Connolly Memorial Hospital, Dublin, and at the Western Regional Sanatorium, for example.

There are many aged persons who, while not ill, are so frail, sometimes physically and sometimes physically and mentally, that it is not possible to care for them effectively in the community. I have been considering how the needs of such persons might suitably be provided bearing in mind that our resources are not unlimited and that even among priority projects, the competition for a share of funds available is intense. In broad terms, we have had to be flexible and pragmatic, however desirable it might have been in a situation of unlimited resources to aim for the ideal. Therefore, in some areas where upgraded services have already been provided in new buildings for long-stay patients the opportunity has been availed of to accommodate on the same sites some of the aged who do not need care of a hospital character in special separate accommodation suited to their needs. In other areas, separate schemes have been planned. A scheme for a 48-place home has been planned for Boyle, County Roscommon, in which county the long-stay accommodation for the chronic sick is being provided at Roscommon town. Tenders will be sought in the near future for this scheme. Tenders are also being sought for a home located at Kilrush which will also accommodate 50 aged persons, the long-stay hospital accommodation being sited at Ennis.

On social and humanitarian grounds I tend personally to favour these small local homes to house the frail who, while still requiring institutional care, do not need hospital care. I have, I might say, directed my Department to consider the question of evolving a standard plan of accommodation for about 40 aged persons which would be capable of being built and run economically and to plan for their provision in future as our resources permit. What I envisage is that homes provided under such a plan would be centrally located, convenient to church and shops as far as this can be achieved. I am happy to be able to report that considerable progress has been made and that we hope that work on about ten such homes will commence this year. A feature of these homes will be that half of the residents will have a room to themselves with built-in wardrobe and wash-hand basin while the accommodation for the remainder is based on the assumption that they will need more supervision and help which could best be provided in small three-bed rooms with convenient toilet facilities.

While much remains to be accomplished in so far as providing for the aged is concerned, reasonable advances have already been made in some areas and a considerable volume of work is in progress. New or reconstructed accommodation has been provided for 1,900 patients. Schemes in progress or for which tenders have been obtained or invited will provide places for 1,400 patients. Schemes in planning will account for another 950, and schemes under consideration will provide for almost 1,900 further places. The total cost of the programme, covering some 6,000 old people, comes to about £12 million.

One of the major improvements in the health services in the past decade has been in the field of domiciliary public health nursing. Ten years ago only a limited service was available, provided to a considerable extent by voluntary agencies such as the Queen's Institute of District Nursing and the Lady Dudley Nursing Scheme. When the needs of the country were assessed some years ago, it was decided that about 600 nurses would be needed to provide a satisfactory service for each area, and by the mid-sixties the halfway stage had been reached towards the target. By recruiting and training about 250 nurses in public health duties in the past four years that target has now been practically reached.

The public health nurse is a most valuable member of the health team in her local community. The duties which she undertakes are many and varied, ranging from the practical home nursing of the aged and chronic sick to the general supervision, in association with the local medical practitioners, of the health of children from infancy to the time they leave national school.

Another important role of the nurse is the health education of the people in her area and she is qualified to speak on matters relating to health and hygiene to school children, to parents or teacher groups, or to other residents or organisations. She is trained to involve herself in the community in which she lives and works, to become the friend and adviser of the families which she meets, and to keep her door open at all reasonable hours to those in need of her help.

The syllabus for training public health nurses has been expanded and further additional courses will soon become available.

I would like now to turn to the care of the mentally ill. The House will recall that a Commission of Inquiry reported in 1966, covering in a most comprehensive manner the whole field of the psychiatric services. In general the commission's recommendations were accepted and, as with the Report on Mental Handicap, the development of services has, in practice, been following for several years the lines recommended by the commission.

I would like to refer to some of the principal developments.

There seems little doubt that we have too many patients in our psychiatric hospitals. The commission pointed out that, at the time it reported, the number of in-patients in our psychiatric hospitals was the highest in the world in proportion to population. At that time the overall number of in-patients was 18,642. In the three years since then it has been reduced to 17,218, a reduction of 1,424. While this is heartening, it is very important that the reduction in numbers should continue; the commission recommended, in fact, that the aim should be to reduce the number of long-stay beds by 5,000 over a period of 15 years, and I am anxious and hopeful that this will be achieved. Every effort must be made to ensure that patients admitted to our psychiatric hospitals receive intensive care so that they may be returned to the community as quickly as possible. Apart from the obvious advantages to the patients concerned of shortening the period in hospital, intensive care reduces the build-up of long-stay patients, take pressure off accommodation which in many cases is still over-taxed, and permits better facilities to be provided for those patients who must necessarily spend a longer time in an institution.

The commission recommended that the grouping of patients in large numbers should be avoided and that hospitals exceeding 750 beds should be divided into smaller units. It also recommended that the contribution and potential of the private mental hospitals should be taken into account in determining the extent of the services which it is necessary for health authorities to provide. Some years ago two of the largest hospitals in this country were St. Brendan's, Dublin, and St. Ita's Portrane. The sheer weight of numbers made difficult the provision of adequate care and treatment in these institutions. With commendable zeal, the health authority set about a scheme which would lead to a very great reduction in the number of patients admitted to these hospitals and would provide a better service for those who needed it.

This scheme involved the administrative division of the mental hospital district embracing Dublin city and county, into seven areas, each having its own team of psychiatrists, nurses and supplementary staff and its own acute unit. There were already two large private psychiatric hospitals in Dublin and in order to provide as good a service as possible, without unnecessary proliferation of hospitals, the health authority had discussions with them. As a result the authorities of the St. John of God Hospital at Stillorgan and of St. Patrick's Hospital, James's Street, have each agreed to provide a full psychiatric service for one of the seven areas. This is the first time in Ireland that voluntary hospitals of this kind have undertaken the provision of services directly on behalf of the public service, and is a development which is most welcome. Both hospitals have long experience in psychiatry and have, I believe, much to contribute to the public psychiatric service. Discussions are also taking place with other hospitals in Dublin and I hope that these will lead to further useful developments. In Cork, new units have been opened at St. Fachtna's Hospital, Skibbereen, and at Sarsfield's Court and efforts to reduce the large number in Our Lady's Hospital in Cork city are continuing. In Galway, a new unit is being provided at the regional hospital.

A very important recommendation made by the Commission on Mental Illness was that, in general, short-term psychiatric care should be provided in psychiatric units in, or associated with, general hospitals. One such unit had already been provided at Ardkeen General Hospital, Waterford, on an experimental basis when the commission reported and since then further units have been brought into operation. I have already mentioned the units at Skibbereen and Galway. Similarly, a new unit associated with an adjacent general hospital has been opened in Clonmel. It is hoped that an additional psychiatric unit will be in operation soon at the County Hospital, Castlebar. There are plans for additional units at Galway (in association with the regional hospital as I have already mentioned) Limerick, Kilkenny and Letterkenny. In addition, it is visualised that there will be psychiatric units at the general and regional hospitals recommended in the Report of the Consultative Council on the General Hospital Services.

For long-term patients, the commission stressed the need for planned and purposeful activity within the existing district mental hospitals. In many of the district mental hospitals occupational therapy and industrial therapy are being developed to fill this need.

Schemes for the renovation and upgrading of some of the accommodation at existing mental hospitals are under way, for example at Ballinasloe, Ennis, Enniscorthy, Cork, Monaghan, Mullingar and Sligo. The improvements include the provision of central heating, new or improved sanitary and bathing accommodation, improvement of kitchen and dining facilities, renewal of electrical and boiler installations, fire precautions, improved staff accommodation and upgrading of furnishing and equipment. Tenders have been received for a scheme of improvements at Youghal and will be sought soon for the provision of a new kitchen and for major improvements at St. Kevin's Hospital Unit at Cork. Proposals are also being considered for improvements at Castlebar, Killarney, Letterkenny, Newcastle and Portrane.

Some new buildings are also being provided at existing mental hospitals. Work is to commence very soon on the building of new units for 100 patients at Kilkenny to replace units that are sub-standard. Patients in these new units will be accommodated generally in six-bed wards which should help considerably in their proper care. The units will have their own separate recreational and rest-rooms and dinning facilities. A 50-bed unit on similar lines is being planned for Killarney.

Another point stressed by the Commission on Mental Illness was the need to develop community as distinct from purely hospital services. There has been a welcome expansion of out-patient clinics. The commission also recommended that a limited number of hostels should be set up on an experimental basis in the larger centres of population. This is being done in Dublin.

The commission emphasised the need to provide for special groups such as children, alcoholics, drug addicts, persons in custody and psychopaths. A special children's residential unit had already been provided by the Dublin Health Authority at St. Loman's Hospital when the commission reported and a day unit at Garden Hill, adjoining St. Kevin's Hospital, was later opened. Three additional units for mentally ill children are now being provided. One has already opened at Beaumont, Dublin, and is receiving patients from provincial areas. A second unit in Dublin which will also receive provincial patients is being planned; the third unit will be in Cork.

So far as alcoholism is concerned I want to make it clear that reports emanating from the Irish National Council on Alcoholism and the Medico Social Research Board have made it absolutely necessary for me to formulate a new policy in a bid to combat this particular form of mental illness. Apart from what it does to its victim, alcoholism causes untold misery and stress to the family and relatives of the alcoholic. I have been told that in some shorter stay private mental hospitals there are more relatives of alcoholics undergoing psychiatric care than there are alcoholics. I must, therefore, examine the whole problem. The public at large have tended to shovel this problem under the carpet. I am removing the carpet.

With regard to persons in custody, one of the commission's recommendations was that the Central Mental Hospital at Dundrum, Dublin, should be retained for certain patients in this category but that it should be administered by the Dublin Health Authority and used for other patients besides custody patients—in particular aggressive, and some non-aggressive, psychopaths. As the House is aware, the Health Act, 1970, now enables arrangements to be made for the transfer of the administration of this hospital to the regional health board. The Dublin Health Authority is actively pursuing the establishment of a department of forensic psychiatry which will embrace the Central Mental Hospital and will involve the linking of the services for that hospital with the psychiatric services of the authority. In due course I envisage a very substantial improvement in the services available at the hospital and their development on the lines of the commission's recommendations.

The Commission on Mental Illness made several important recommendations as to medical education and training. We now have four chairs of psychiatry in Dublin where previously there was one. Chairs have been created in Cork and Galway and steps to appoint professors are in train. This alone is a considerable advance and should result in a much-needed improvement in undergraduate medical education. One in every three or four cases coming before a GP has psychosomatic content or presents a psychiatric problem. No matter how much we increase the number of psychiatrists, doctors generally must receive far more extensive psychiatric training in future.

By co-operation between the teaching bodies, Dublin Health Authority and my Department, a post-graduate course in psychiatry started in Dublin last autumn and at present 41 doctors are undergoing a planned and systematic course of training. The extension of the scheme to other areas later this year is at present being examined.

The commission recommended that there should be a positive programme of public education in regard to mental illness. The Mental Health Association of Ireland will help in this respect. It was established in 1966 and has received financial assistance from my Department and the health authorities. I might mention that its establishment was also in accordance with a specific recommendation of the commission for the setting up of a national voluntary body.

The commission recommended that a national advisory council should be established which would provide advice on any matter relating to the mental health service. As I will shortly indicate to the House a somewhat similar recommendation was made by the mental handicap commission and I have decided to implement that recommendation in a slightly modified form. On the mental illness side, however, I have not yet decided to implement the commission's recommendations for the establishment of an advisory council, as I am not satisfied that this would be desirable just now. We are at the moment at a transitional and active stage in implementing the very many recommendations of the Commission on Mental Illness. The commission have themselves provided expert advice in relation to a vast field of endeavour and, as I have already indicated, there is substantial agreement on the measures which now need to be taken. Our immediate problem accordingly is to implement generally accepted improvements. Later, when this has been attended to, the need for a national advisory council can be more fully considered and this will be done.

I would draw the attention of Deputies to the growing concern expressed by consultants at the huge and increasing intake of anti-depressants, tranquillisers and sleeping pills by ordinary people not requiring intensive psychiatric care. The level of consumption in this country seems likely to compare at some future date with that in Britain where, according to Sir Derek Dunlop, the former chairman of the British Drugs Advisory Board, there were 45 million prescriptions under all these heads in 1968 and where 10 per cent of the hours of sleep were drug-induced.

Recently 18 leading British consultants expressed grave concern about this trend, arising because the human personality is not, even at its best, particularly strong and in the reported words of Monsignor Jeremiah Newman, president of Maynooth College, in a recent and thought-provoking address to the Christus Rex Congress "one of the gravest problems of our day is that the social environment of contemporary urban industrial society is tending more and more to be anything but conducive to the best development of the human personality". The full impact of urbanisation on the human personality has not yet hit us in this country, although there is evidence to show that it is developing and will be developing further to become a serious problem to a Minister for Health endeavouring to improve the mental well-being of the community.

Man's material and scientific progress and achievement have tended on the one hand to give him a superiority complex blinding him to his inherent weakness and at the same time exposing him to pressures he does not fully understand. The mass media with their inevitable concern with disaster, war, disorder and crime represent another aspect of the pressures of modern society and it is not difficult to see that modern men and women, because particularly of the visual impact of television, must feel that they belong to a generation set upon as no generation was ever set upon—and this despite better living conditions and standards and well developed social services. The vulnerability to stress is all the greater when the established order, cultural, temporal and religious is being questioned and is in some disarray on all sides. Then, too, impatience with discipline and restraint of any description impels modern man to a frenetic search for a utopia which does not, and indeed I suppose cannot, ever exist. And so when the inevitable letdown happens the anti-depressant and the tranquilliser is turned to.

I would make it clear that I in no way wish to interfere with the right of practitioners to prescribe these anti-depressant and tranquillising remedies. Rather do I wish to bring all the professions concerned together to discuss this growing trend of over-indulgence in these panaceas to see whether there can be modifications of treatment, more moderation in prescription and, above all, the use of other procedures. Alternative procedures involve questions of time, staff and training, and may pose problems not easy to solve. I intend to seek the advice of experts —medical, psychiatric and religious— on these problems and, if necessary, to appoint a special group to examine them and suggest solutions.

I have mentioned some, but only some, of the very many matters calling for our continued and urgent attention in the very wide field of the psychiatric services. They indicate in broad outline the need for a progressive and determined effort to develop and improve these services and I envisage this proceeding in as organised and systematic a manner as possible.

As with mental illness a commission of inquiry surveyed the whole field of mental handicap and furnished a comprehensive report. This report was circulated widely and the views of various interested bodies and individuals were obtained. There was little disagreement with their findings. The development of services in this country has, for several years, followed the pattern recommended by the commission; the report has been of considerable value in this respect.

The commission gave considerable thought to the question of numbers. It may seem a simple matter to find out how many mentally handicapped persons there are in the country. This is not so. There is, first of all, the problem of finding those who may be mentally handicapped. Their full diagnosis and assessment requires the services of a skilled team and the full assessment of many involves examination over a period. In practice, exact figures as to the total number of the mentally handicapped are not available in any country and estimates vary widely. Instead, therefore, of providing an estimate of numbers, the commission wisely, in my view, on the basis of all the information available to them and including information from other countries, recommended targets for the development of services for the immediate future.

I know that many Deputies are particularly interested in the provision of residential accommodation. Here the commission recommended that the target should be of approximately 2,700 additional places in special residential centres. When the commission reported in 1965 there were a total of 3,100 places available. There are now 4,050 places. I have circulated particulars of these to Deputies, and also of an additional 1,500 places which are in course of construction or are being planned, and which should become available over the next three or four years. It will be seen, therefore, that the targets set by the commission in regard to residential places will be met almost completely. The only exception is in regard to residential accommodation for the mildly handicapped to which I will refer later. I am deeply conscious of the fact that, at the moment, a waiting period is often necessary before a child can be admitted to a residential centre and this can cause considerable hardship, particularly in the case of the moderately or severely handicapped. I can assure the House that the provision of additional accommodation is being pressed ahead as much as possible. When this accommodation is available the waiting period should no longer be a problem.

One of the most heartening features of developments in recent years is the rapid growth in the numbers of mentally handicapped being dealt with on a non-residential basis. The commission accepted, as a general principle, that community care, that is care provided outside residential centres, is therapeutically better for a handicapped person in that it permits a fuller development of personality and avoids the difficulty of adjustment to normal life which is frequently experienced after prolonged care in an institution. At the time the commission reported there were some 600 receiving services on a non-residential basis. By the end of last year this number had increased to 2,400. I have included details in the information circulated to Deputies in connection with the Estimates.

In regard to the mildly handicapped the commission recommended that the targets should be to provide services, either on a residential or a non-residential basis, for approximately 5,000 children of school-going age. I might explain that provision of educational facilities for the mentally handicapped, mild and moderate, is the responsibility of my colleague, the Minister for Education, while I deal, broadly, with all residential services, but our two Departments work in the closest co-operation on these matters. It is feasible to provide services on a day basis for a large proportion of the mildly handicapped. At present services are being provided on a day basis for 1,300 pupils and on a residential basis for 900 pupils. Here, too, it will be seen that considerable progress had been made towards meeting the target set by the commission. In the provision of residential accommodation, however, priorities have naturally to be determined and it was decided to concentrate on accommodation for moderately and severely handicapped children and for adults. The provision of accommodation for adults is essential if the centres designed for children are not to become saturated with adults who cannot be restored to the community after their training and education as children. Since the commission reported some 200 residential places have been made available for the mildly handicapped; but until I see to what extent the population can be catered for on a day basis I have decided not to increase the residential accommodation for this particular class but, as I have said, to concentrate on accommodation for the moderately and severely handicapped.

Concurrently with the increase in the extent of services, improvements are being made in the standards of services. In the past it was accepted that custodial care was all that was feasible and, indeed, necessary. The commission placed great emphasis on the need for training and education to enable the mentally handicapped to make the best use of their abilities. This, of course, requires skilled staff. We have not solved all our problems, but there has been a very welcome increase in the numbers of doctors, specially trained nurses, psychologists and specially trained teachers available for the provision of services. We are still short in many areas of an adequate number of physiotherapists, occupational therapists and speech therapists, but we are trying to rectify these matters as quickly as possible.

One of the recommendations of the commission was that an institute of mental handicap should be established. I have decided, however, to establish a consultative council which on its own initiative or at my request can make recommendations in regard to any aspect of our mental handicap service. The council will be broadly representative of those caring for the mentally handicapped and I am sure it will be of considerable help in securing that, in a short time, our services for the mentally handicapped will be as good as those in any country in the world. I have already been assured by independent specialists in mental handicap who have travelled abroad that we are generally ahead of all but two countries in Europe in our services and we owe a tribute above all to the religious orders and also to the lay associations who have made this possible.

Current expenditure by the State and health authorities on the maintenance of the mentally handicapped, that is, excluding capital expenditure, is considerable and runs to about £4 million in a year. The current programme for residential places will cost £3 to £4 million—excluding capital expenditure on schools which is the concern of the Department of Education—and will, at present money values, add about £1 million to the annual maintenance costs.

While it would be idle to pretend that our dental services are all that one would desire, nevertheless there have been considerable improvements in the public dental service in recent times. Dental clinics with modern equipment have been provided in most health authority areas. The number of whole-time dental officers employed in the service has increased from 74 in 1959 to 118 in 1970 and there has been a welcome willingness for more private dentists to provide sessions for health authorities—the number doing so has increased from 61 in 1959 to 98 in 1969.

It has been departmental policy to encourage health authorities to increase the number of dental officer posts and to appoint senior dental officers to supervise and promote the development of dental services. Chief or senior dental surgeon posts have been created in 18 health authority areas and it has been the experience that the appointment of such staff has resulted in a major improvement in the services provided. Improved conditions of service and remuneration for public dental officers were introduced in January, 1968. For incremental purposes credit was allowed for previous experience in dentistry and dental officers were permitted to provide up to two additional sessions per week, outside normal working hours, at special fees. The current scale for a dental officer compares favourably with the salaries paid for similar posts in Britain. This has been reflected in the improved recruitment in the past two years when twenty new appointments were made to the service.

It will be continuing policy to try to keep up improved recruitment to the public dental service so that the dental services for those who are at present eligible may be brought up to a reasonable standard. Until this position has been reached it will not be practicable to extend dental services to other categories of persons. In any event, experience in other countries has shown that, even with optimum staffing and clinical facilities, the dental caries problem cannot be solved by treatment methods alone. For this reason emphasis must continue to be placed on the education of the public, particularly the children and teenagers, in dental hygiene and on preventive measures like the fluoridation of public water supplies.

Since the programme for the fluoridation of public water supplies was initiated some years ago, fifty-three public water supplies have been treated, serving a total of about 1,300,000 persons, including those in the major urban areas of Dublin, Cork, Limerick, Waterford, Galway, Dundalk and Drogheda. A total of two million people are served by piped supplies but it is estimated that only 1? millions of these could be given the benefit of fluoridation because many of the supply schemes are so small that they would not be suitable for the installation of fluoridation equipment. Supplies serving an additional 161,000 people, are expected to be fluoridated during 1970. It is intended, as far as is feasible, to treat within the next five years all public water supplies which serve 1,000 persons or more.

It has been clearly established that fluoridation results in a substantial improvement in dental health, especially in the case of children. We should be able to achieve a similar result here. A special committee is supervising a long-term scientific study, which commenced in selected areas in County Cork, in June, 1967, to measure very precisely the effects of fluoridated water on children's teeth. Studies are at present in progress also to assess in a more general way the effects of water fluoridation on Dublin city and Cork city school children after about five years' experience of water so treated. Meanwhile, it is of interest to note the results, recently published, of the interim study carried out by the dental staff of the Kildare County Council into the incidence of dental decay in first permanent teeth of children in Naas, where the water supply has been fluoridated since 1964. The survey claims a reduction of 25 per cent in decayed first permanent teeth of children in the combined age group 7-10 years after five years' fluoridation and a reduction of 64 per cent in such decay among seven year old children who experienced fluoridation from two years of age. This survey, though limited in scope, tends to confirm similar results obtained elsewhere and is a hopeful pointer to the long-term effects of fluoridation in other fluoridated areas of the country.

Concurrently with the programme for fluoridating public water supplies, the Department has asked health authorities to consider promoting, in areas where fluoridated water supplies will not be available, schemes for the topical application of fluoride by means of regular mouth rinsing by children with a suitable solution.

So far as education in dental hygiene is concerned, I am with the co-operation of Radio-Telefís Éireann, in process of having dental educational filmets made for showing on television aimed primarily at the young. These will supplement the other efforts of my Department—notably the school film shows—and of the dental health education committee of the Irish Dental Association who do such excellent work in this particular field.

Since I became Minister for Health questions relating to drugs and their control have commanded a considerable amount of my attention. The largest overall problem was that relating to medicinal products generally. I am preparing legislation and hope to introduce it later this year, which will enable me to apply a comprehensive system of statutory controls for ensuring the safety, quality and efficacy of all medical preparations available on the market in this country. The need for such controls is bound up with the pharmaceutical revolution of recent decades and with developments in other countries. Not only have such controls become essential for the protection of the public but they are also seen by the pharmaceutical industry as a logical prerequisite in safeguarding the prestige of its products and in facilitating international trade both now and in the years ahead.

In the meantime the service operated by the National Drugs Advisory Board for assessing the safety of new drugs has been working smoothly since it commenced in 1967. This service depends on the voluntary co-operation of the pharmaceutical industry, and its success, for which the board and the industry deserve the highest praise, augurs well for the future when the procedures involved will have the force of law. Side by side with this activity the board have an effective system for recording adverse reactions to drugs which are discovered by doctors in the course of their hospital and private practices and for supplying information to the medical profession based on its assessment of the data available from these and other sources. In addition, the board has, during the past year, commenced a service for providing all doctors, at regular intervals, with up to date information on various classes of drugs. This service, as well as enabling the medical profession as a whole to keep abreast of the latest developments in therapeutics, should contribute greatly to stability and rationalisation in prescribing.

Draft poisons regulations have been prepared by my Department. This draft, which is a lengthy document, was based, on recommendations made by Comhairle na Nimheanna. When the regulations have been enacted they will form a comprehensive system of control over a wide range of toxic substances and will replace existing controls contained in the Poisons and Pharmacy Acts and in the earlier regulations made some years ago. The new controls will cover conditions of sale, labelling, storage, the registration of manufacturers and wholesalers and the licensing of sellers of agricultural poisons, other than pharmasicts.

As they are so far-ranging, I decided to give all interested bodies an opportunity to comment on the proposals at the draft stage and accordingly invited their observations. The consultations were widespread and a large number of organisations have submitted their views. These are at present being examined and will be considered in compiling the final draft.

I might say at this stage, however, that very many of the comments deal with what I might call the agricultural poisons, which are an area of some controversy and it will be necessary to have detailed discussions with the Department of Agriculture and Fisheries before arriving at final decisions on a number of the substances.

A more disturbing problem, perhaps, is that of drug abuse. A working party had been established to consider certain aspects of the problem in this country and shortly after I took up office they submitted certain interim recommendations to me. These concerned matters which, the working party felt, could be dealt with in advance of their final report and in some respects the recommendations were an endorsement of action which I had already taken. While I do not wish to go into too much detail at this stage, there are a few points to which I should like to make special reference. Section 76 of the new Health Act will enable me to make the unauthorised possession of certain drugs a punishable offence. I expect to be in a position to make the relevant regulations in the near future, following consultations now in progress with a number of bodies in a position to assist me in their preparation.

So far as amphetamines are concerned, I consulted the medical profession regarding possible curtailment in their use and when I met representatives of the profession to discuss the matter there was unanimous agreement that statutory measures should be taken to restrict the availability of these drugs. I, therefore, made regulations in December last prohibiting the manufacture, importation and sale of amphetamines and certain analogous substances, subject to the granting of licences in exceptional cases.

So far as the prevention and treatment side of the problem is concerned happily the position has not been reached where large numbers of persons are in need of care for drug dependence. There had been, however, a long-felt need for special facilities where drug abusers could get the kind of advice and treatment they required and I am grateful to the Dublin Health Authority and Jervis Street Hospital for their co-operation in the provision of a combined out-patient and residential care service which is now fully in operation.

There is a growing awareness on the part of the public of the importance of measures designed to ensure the quality and safety of food for human consumption. This is recognised at international level through the work of the Codex Alimentarius Commission which is sponsored jointly by FAO and WHO and of which this country is a member. The commission, working through a series of committees, is at present engaged on the drawing up of standards for all the principal foods whether processed, semi-processed or raw. Each standard will contain requirements aimed at ensuring for the consumer a sound wholesome food product, correctly labelled and presented. Each standard will include provisions in relation to description, essential compositional and quality factors, additives, including pesticide residues, contaminants, hygiene, labelling, methods of analysis and sampling and weight.

The National Codex Committee which was recently set up by the Government will advise on the acceptability from this country's point of view of the standards as they evolve. Legislation will be necessary to enable this country to comply with the accepted standards and any such legislation will involve other Minister besides myself, including the Minister for Agriculture and Fisheries and the Minister for Industry and Commerce.

In the meantime, amongst other matters being examined by the food advisory committee which was established under the aegis of my Department, are the problems associated with the presence in food of pesticide and antibiotic residues. The question of antibiotics in food is further complicated by the phenomenon which is now referred to as infectious or transferable drug resistance whereby a micro-organism which is resistant to one or more antibiotics can transfer such resistance to other microorganisms although these have not been exposed to the antibiotics concerned.

My predecessor appointed a committee to advise on the measures which should be taken, in the interest of public health, to further and maintain a programme of education and training in food hygiene and other related aspects of hygiene. I understand that the committee has almost completed its work and I await its report with interest.

In the field of international health this country continues to play an active part. Our co-operation with the World Health Organisation currently includes carrying out a pilot scheme of registration of ischaemic heart disease. This scheme, in which we are co-operating with 15 other countries, is part of the world-wide effort to combat cardiovascular diseases. We are also taking part in a World Health Organisation project in relation to drug monitoring which provides for an international exchange on drug reactions. In Europe our full participation in the work of the Council of Europe public health committees includes representation on the committee of specialists in blood problems which is holding its next session in Dublin in May. Apart from contributing to the international effort to combat ill-health, co-operation with these organisations gives this country the considerable benefits derived from exchange of information, control of communicable diseases and access to facilities such as the exchange of blood and blood products. Irish men and women also, and the universities, hospitals, laboratories, surgeries or other areas where they work, benefit directly from the fellowships allocated annually to this country by the World Health Organisation and the Council of Europe. In the context of our application for membership of the European Community the practical demonstration of our interest in European co-operation in the field of health should also be of value. The steps which we have already taken to comply with the agreements and recommendations of the Council of Europe public health committees will, of course, facilitate our entry into the European Community.

Deputies will have observed from the material circulated to them in advance of this debate that there are over thirty bodies, committees or organisations which operate in conjunction with my Department in either an executive or advisory capacity or in a combination of both capacities. The vast majority of persons on these organisations act in an unremunerated capacity giving of their spare time and energies in a public spirited desire to serve the community. Their work is of invaluable assistance over a wide ranging area of the health services and it is, I think, fitting that I should include in this introductory speech on the Estimate for my Department a "Thank you" on all our behalf to these people.

After only some months of experience as Minister for Health, I still, naturally, have to continue studies of our health problems before I could attempt comprehensively to list the priorities in health matters with absolute precision. At this initial stage I am, I feel, on safe ground in listing the following matters as being essentially part of any list of long term and short term priorities which I will draw up:

Improvement of the child health services with the emphasis on the early detection of abnormalities, defects or diseases in infants and children.

An expanded and more detailed health education programme with an emphasis on the prevention of coronary disease and encouragement of the public towards the use of preventive services such as vaccination and immunisation.

An expansion of screening services.

The attainment of the accommodation goals we have been set for the mentally handicapped.

Accepting that psychiatric illness, mild and grave, will become an ever-increasing problem and preparing to meet the shortage of psychiatric personnel.

Encouraging the extension of the formation, wherever required, of community associations to engage in a co-ordination of facilities, central and local authority and voluntary, for young and old.

Improving and integrating the whole hospital service with special emphasis on better outpatient diagnostic services following the advice of the FitzGerald Report and the improvement of domicilary services generally.

Applying consultant management techniques to hospital administration.

I should like to commence by expressing my gratitude to the Minister for the circulation in advance of the debate of a 79-page memorandum dealing with some of the fundamental information which it is very necessary for Deputies to have in order to bring mature consideration to our health problems. I should like also to express my gratitude to him for giving a 47-page opening statement today even though it made, as he would appreciate, great demands upon his audience as it did upon himself, demands which make it impossible to absorb all the lessons which the Minister would wish us to take from what he has said.

If, in the course of my remarks, I express disagreement with the Minister on a number of points he will understand that I am discharging my obligations as a Member of the Opposition in being the devil's advocate and pointing out that the ministerial carpet over which the Minister has walked still has a considerable amount swept under it. Even though the Minister is prepared to remove the carpet in relation to the problem of alcoholism he would need to remove much longer stretches of carpet in order that the full picture would be understood. It is, however, a heartening development in health debate in our country in recent times that people in all walks of life are prepared to go to a great deal of trouble to find out the extent of the problem and, on learning the extent of the problem, to make the necessary sacrifices to overcome the difficulties with which their neighbours may be afflicted. It is only by a proper assessment and by an honest admission of the extent of our many health problems that we will ever reach out.

The Minister has recited with, I think, some degree of justification, the considerable progress which has been made in recent times in relation to the provision of accommodation for people who are mentally handicapped. There are other aspects of encouraging development in our health services. It is true to say that these would never have occurred if there had not been the catalyst of discovery in the first instance. if the problem had not been correctly assessed and if the degree of shock necessary to cause development had not originated in the first instance from a thorough examination of the problem and an admission of the problem when found.

As the Minister will appreciate one would certainly like to add to the list of eight priorities which he gave at the conclusion of his speech. However, one of the essential things about priorities is that everything cannot be made a piority and if one were to do so one would probably achieve very little. Certainly progress would not be made in the more vital aspects of public and private health. Therefore, I shall not engage in any competition with the Minister as to what the eight perfect priorities should be but I may indicate a number of lines upon which I am disappointed that the Minister has not committed himself more vigorously.

I was very interested to note from the vital statistics the Minister furnished to us in advance of the debate that the number of deaths from accidents in the home had trebled over the last ten years. This is a very disturbing development. It means that the home is now a more dangerous place to be in than the public throughfare because we have more people dying at home from accidents than we have from traffic accidents on our roadways. Very serious consideration must be given to the need for an immense programme of public education so that the many simple accidents which occur in the home can be avoided. There does appear to be some ground for believing that a number of accidents in the home arises through the misuse of electricity; there has been a considerable increase in the number of accidents and deaths in the home caused by the use of defective electricity. In this field we have the problem of divided responsibility between the Minister for Industry and Commerce, the Minister for Transport and Power perhaps, and the Minister for Health. It is a region which quite clearly justifies emergency action on the part of the State to bring people to a realisation of the terrible tragedies which are occurring in the most simple and avoidable ways in their own homes, in the places which are understood to be safe.

I was very interested to see in a newspaper last week an advertisement for a life insurance company which illustrated a nice, comfortable drawing room. Indeed one looking at it thought it was just so, the kind one might see in any normal home. Then there was a list of the several things that were wrong—defective power points, triple and quadruple power points and some electric wires connected with pieces of sellotape and highly dangerous substances of that kind; kettles of boiling water in dangerous positions; a fish bowl on top of the television set; clothes hanging in front of the fire and many substances, articles and many other things in places which are common in the home.

The Minister mentioned that a considerable increase in death has arisen particularly in relation to accidents to old people. We are, as the Minister has correctly pointed out, anxious to see a larger number of old people being well cared for outside of expensive institutions and living satisfactory, ample, full lives in their own homes and in their own communities. If this development is to take place, as we believe it should be encouraged to take place, we would certainly need greatly to increase the schemes of advice to those people so that many of these accidents will be avoided in the future. If we develop, as we have been developing, the system of public health nursing and home visiting we will perhaps reduce the number of causes of accidents in future. This is one of the most startling stastistics of those offered to us and as the causes of these accidents are in most cases simple we should endeavour to avoid the consequences by the very simple method of educating people.

There is another very worrying statistic in the figures given by the Minister. That is the tremendous multiplication in the number of cases of gastro-enteritis in children under two years of age. Gastro-enteritis is an infection which frequently is caused by poor housing and the fact that we can jump from 1,579 cases of gastro-enteritis in children under two years tinue to rely entirely on a purely volun- of age in 1959 to 2,660 in 1969 is a very sad reflection on the housing conditions of a large number of young families. The truth is that over that period it has become increasingly more difficult for young married people with young children to get suitable housing accomodation.

This has been reflected in urban areas in particular; where the overcrowding is of considerable magnitude there has been a considerable increase in the number of children suffering from gastro-enteritis. This arises out of bad housing. Gastro-enteritis is a condition which cannot be treated where housing is poor and where overcrowding exists. Perhaps what has also happened is that a number of these cases which could be treated in homes if home conditions were adequate have had to be treated in fever hospitals and have come more to the notice of public authorities on that account.

I realise that all cases of gastro-enteritis under two years of age must be notified, but there is not infrequently a difference between the obligation and the performance. Where any disease is treated at home it is less likely to come to public notice than if it goes to an official institution. There is a lesson to be learned from this and it is the consequences that flow from poor housing.

This, of course, does not paint the full picture of human suffering, misery and immense strain which lie on the mothers in particular of children who suffer from this unfortunate disease. The Minister mentioned in his valuable brief the woeful burden of mental illness in this country and he recited a number of possible causes. With some of them I would not disagree, but he does not mention, sweeping it under the carpet, bad housing, overcrowded conditions.

It is a common complaint of young people looking for houses that the young mother is suffering from her nerves. You will find all too frequently that there is medical evidence to support the complaint of the colossal strain from which young mothers are suffering because of bad housing conditions and it is vitally necessary that these conditions be improved so that immense human suffering may be avoided. It is important also from the Minister's point of view, and he appears to be concerned with economics, because the financial burdens on him would be lessened considerably.

Those concerned—general practitioners, public health nurses and all those concerned with social affairs—are all too aware of the manner in which the health of whole families is affected by the necessity to live in slums. The slums these days may not be in decaying Georgian buildings: they exist in modern housing estates which may have been constructed 18 or 20 years ago in which in many cases two or three families live under one roof, with immense pressures on the people so living. Therefore, the more the Minister can do to relieve these pressures the more likely it is that there will be corresponding relief of pressure on the health institutions for which he is responsible.

The inadequate investigation of drugs is a sad reflection on the Government. I think the situation is fast developing in which Ireland is becoming one of the worst countries in Europe in relation to the investigation and the management of drugs. Members of the House have brought to their attention from time to time cases in which drugs which have been forbidden in other countries are no sooner forbidden there than they have flooded into this country, the manufacturers simply exporting their problem into the Irish pool, and this has brought about a situation in which Ireland, once one of the safest countries in Europe, is fast becoming one of the most dangerous as far as the availability of drugs is concerned.

The Minister said that the National Drug Advisory Board are looking at the problem. They are, and all due credit to them for what they are trying to do. They are, however, a body which depend on voluntary co-operation. They are listed by the Minister in his 79-page memorandum as a voluntary board. We will not grapple with this problem with the degree of urgency and skill required if we contary board. We need to have the best qualified people available in order that our community may be protected in time against the very serious consequences of consuming these drugs. I am talking now about the consequences if drugs are taken in the wrong dosage. Without the care necessary they become very dangerous indeed.

Another great danger is developing because of the continuing damage to our own environment and the inhalation of poisonous substances in the air and the consumption of impurities in food and drink. The Minister referred to the work of the food advisory committee. However, although welcoming work in this field, one must complain that the amount of care necessary to protect our food has not been taken. We need a great deal more activity in relation to food. The truth is that many foods consumed in Ireland contain substances which are absolutely prohibited in other European countries.

We have been all too reckless, for instance, in embarking on water fluoridation when we had no knowledge of the content of fluoride in food in regular consumption. Recent findings in England, where some care has been taken in relation to fluoridation, have established that the content of fluoride in tea is nine times higher than what was thought ten years ago. We are one of the greatest teaconsuming nations in the world and yet we are one of the few which have compulsory fluoridation of water. This should be causing grave concern to the Minister, but it is not. He could not push ahead with fluoridation although he does not know the fluoride content of a vast number of foods and drinks daily consumed in Ireland. This can vary from one country to another and we, an island race, should be very careful before we embark on a scheme of mass fluoridation. The Department of Health which, a few years ago, completely rejected the idea of the application of fluoride, are now explaining the topical application of fluoride in some areas. One wonders why it is that all our people have to be exposed to the results of the consumption of fluoride when the reasonable alternative is its topical application to children's teeth, something which was always available.

I am aware, of course, that this change of heart on the part of the Minister and his advisers has not arisen out of any care for the principles involved or out of any realisation of the dangers involved in the mass medication procedure which has been rejected by most countries in the world where care is taken in regard to these matters. It arises simply out of a matter of convenience in those areas where our public water supply is not considered to be suitable, to be adequate or to be available for the purpose of fluoridation.

One of the great problems in this field is illustrated in the Minister's brief, the apparent obligation on the Minister for Health not to do anything in relation to the content of food or the availability of drugs and pesticides without prior consultation with and the permission of the Department of Agriculture. The Minister has an over-riding obligation to men, women and children to transend any economic consideration or any matter of convenience to any other activity in the community. Without in any way deprecating or taking credit from the benefits which have been conferred on mankind by the chemical industry in the production of food and in the improvement of environment, one must take care that these benefits are not destroyed by being careless with the weapons which have been made available to us.

Man has only two lives. One of these lives is eternal while the other is the life here. We have some say in determining where we will go in the next life but in this life we often have very little say in determining where we spend our time but if we have a say we should exercise that say. I consider that there is not a sufficient realisation of this matter. This year we are concerned with advancing the cause of European conservation. However, I fear that at the conclusion of the year the attention and care which ought to be given to man's own environment will be put in the background. It is not one of the matters which the Minister considers to be one of his eight priorities. I am aware that the problem is a difficult one and I am not pretending that it is the Minister's most urgent function but it is a problem that is always with us and I should like to see a special section of the Minister's Department being set up to deal with the problem on a continuing basis so that we will not allow a situation to develop where we might regret the so-called advances of mankind.

There have been a disturbing number of deaths from Paraquat poisoning. The severest penalties should be imposed on anybody who sells Paraquat or any similar poisons in unlabelled bottles. We were made aware recently of a case in which a coroner investigating a death arising out of the consumption of this substance said that he went to three shops where the poison was on sale and in two of the three shops he discovered that it was on sale in unlabelled bottles. Surely it is an indication of absolute recklessness and indifference to the welfare of people on the part of anybody who puts such a substance on sale in an unlabelled bottle, one mouthful of which could prove fatal. It is equal to selling gunpowder as sugar or to selling cyanide as flour. The Minister for Health and other government agencies should make every effort to stamp out activity of that kind.

I am as partial to gardening as the most enthusiastic gardener. In fact, it is about the only hobby for which I find time to apply myself and I am as anxious as any other to use pesticides and weed-killers that can increase production of flowers and necessary food and remove drudgery, but if poisonous substances are available for sale in unlabelled bottles the price to be paid is too high for the benefits I have mentioned. If these poisonous substances are to be misused this island of ours, which has been spared a great deal of the blemishes which man has brought on his environment, could become as miserable as that of other places. During this happy season when we awake to the singing of the birds we would not like to think of having a silent spring. The danger at the moment is that the matter is being put on the long finger and that it is really on the fingers of two different ministries. Therefore, I would urge the Minister for Health to take a firm stand with the Department of Agriculture and insist that human welfare should come first.

We are very disappointed that the Minister has not yet introduced the much promised legislation to deal with drug abuse and that he has not yet made the regulations under section 76 of the Health Act which would render the unauthorised possession of certain drugs a punishable offence. We can appreciate the need for consultation but at the same time we are aware that there is more than sufficient information available to the Minister in relation to this matter not only in this country but throughout the world. It is inexcusable that in relation to this appalling matter the Minister should delay for one day longer than is absolutely necessary. There is a growing addiction to narcotic drugs on the part of a large number of people and for a considerable time now this addiction has been growing. We are aware that the Minister's predecessor was not anxious to admit that there was a drug problem in our midst.

I was surprised to see recently that figures supplied, I presume, by the Department of Agriculture to the Council of Europe, stated that there were only 62 drug abusers in Dublin. I do not know when the information was given by the Department or on what year it was based but it is the information that is at present available to the Council of Europe. The world may be indifferent to our problem in this regard because it is not as great as the problem in other parts of the world but if we try to cod the world by pretending the problem is less than it really is we should not try to cod ourselves. I would ask the Minister to lift the carpet and to see what the problem is like underneath.

The Minister has paid a deserved tribute to the Dublin Health Authority and to Jervis Street Hospital for the development of a special drug advisory unit and for the provision of a unit for the care of addicted people This is only a beginning of the attention which is required for this problem.

I share the reservations which the Minister has and which his predecessor and others have about talking too much about this matter lest, by emphasising it, you stimulate curiosity, interest and sampling, which could have most damaging consequences. Having said that, let us not pretend we have not the problem: we have. We hope that the much-promised and long-delayed legislation will soon be introduced.

There is one aspect of our health service which has been played down by the Minister and by successive Governments, namely, the need to have an entirely contented medical, nursing and ancillary staff to operate it. We know from the parable of the labourer in the vineyard, and earlier in human history, that contentment and pay and conditions of service are inseparable. It is now at least two-and-a-half years since the then Minister for Health told this House that he expected to complete shortly satisfactory negotiations with the IMA and the IMU on the matter of the remuneration of doctors under any new health service. I have not the debates of March, 1968, with me but I was looking at them within the past 48 hours. I doubt if there is any significant difference between what the then Minister was saying about the anticipated conclusion of satisfactory negotiations and what the Minister for Health said today. The principal difference between them is the period of two years that has intervened. We would appear not to be any nearer to the conclusion of satisfactory negotiations or to be any nearer finality in the matter.

I can only talk from appearances because the Minister and his predecessor have declined to tell us the problem and I can proceed only on hearsay, but apparently the Minister and his advisers are anxious to see a health service here operated on the basis of remuneration similar to that which has not successfully operated in Britain. To my mind, that seems to be folly unto the nth degree. A large number of countries whose economies are similar to ours are successfully operating a fee-for-service health scheme.

That is the basis of our negotiations.

A great deal of the delay, as the Minister must be well aware, arose out of the fact that the Department were not prepared, originally, to accept the principle of a fee-for-service. A great deal of useful time was lost by the efforts of the Department and the Minister to press a system which was unacceptable to the medical profession. I am since aware that when there was a change of heart new terms were offered to the medical profession but these terms required the medical profession to work under conditions and for hours which would not be tolerated by any trade union or professional organisation other than the medical service, with its long tradition of service. We have an obligation to doctors in this day and age. If we do not give them reasonable, human conditions in the operation of their noble profession they will naturally go elsewhere. We have a large output of qualified people from our medical schools but 75 per cent of them go abroad and earn their living abroad all their lives. There are regions of our country where it is becoming increasingly difficult to get a doctor. The truth is that we need more doctors if we are to give the doctors we have reasonable conditions. We will not give the doctors we have reasonable living conditions if we are niggardly in this field.

This will bring me later to another point which I notice is not touched upon in the Minister's brief; it is not considered even to be one of his priorities although it is one of the things which we were told in the Government's Third Programme was having the attention of the Government and was then under current examination. I refer to the whole basis of the financing of the health service. Apparently the Minister is not even thinking of it. It can be argued that the total cost is all that matters and we can have a discussion some other time about the best means of financing the health service but that is not entirely true. If you have money from the proper sources you will be able to get money for identifiable services. So long as our medical and health services— essential services—are in competition with the vast range of politico and cultural and inessential services then health and medical services will probably come well down the list of Government priorities.

The Minister said he had no wish to indulge, in relation to hospitals, in politico-ministerial humbug. In all States—we are no exception—there is a considerable amount of politicoministerial humbug in State revenue and State expenditure. You cannot consider that our whole health and hospital services can be separated from those considerations because those very considerations from which the Minister, in his sincerity, wants to escape—and I think properly escape—are there and curtail the amount of money available for the very services he wants to perform, and curtail also the remuneration which doctors require, properly require, for the giving of their services to the community.

I am aware, as indeed everybody else is aware, of the readiness of the medical profession to give their care without remuneration in necessitous cases. No matter what scales are negotiated or what terms are fixed or what fees are prescribed I am aware that, in the future as in the past, we shall have doctors who will give their skills, care and labour without regard to cost. That does not remove from us our moral obligation to ensure that these people are adequately remunerated. Most of them are married, have families and have their social obligations. If they are not able to maintain themselves without worry, concern and anxiety it will reflect itself in the care and attention given by even the most dedicated of doctors.

There is a problem to which I would particularly ask the Minister to give some attention. It arises in respect of doctors who operate on a sessional basis in hospitals. I know that a superannuation scheme has been introduced for whole-time, permanent doctors in hospitals. This is something which we welcome and it is long overdue. I would ask the Minister to consider the problem of a doctor who is attached to a hospital because he is bringing some particular skill to that hospital or perhaps to a number of hospitals. If the doctor falls ill there is no fund available out of which to make him any payment during his illness. The result is that his family have to fend for themselves. Sometimes these illnesses can be of considerable duration.

We believe that a scheme should be developed for doctors who are operating in those rather unsatisfactory conditions at present. If they were provided with a superannuation scheme similar to that available for the whole-time permanent staff that would help them in relation to their retirement, but it is also necessary to have a scheme which would go a great deal further so that their income could be maintained during periods of illnesses.

I know there are difficulties in the administration of such a scheme but they are not insuperable. Where there is a will there is a way. The Minister should give very careful consideration to this problem, particularly as he has quite clearly given a great deal of care and thought to the development of the whole hospital system and the consultants and other staff who will be associated with the new hospitals.

At one time it was thought that Irish nurses were as plentiful as the leaves on the trees and that we would never be short of them, but we are now experiencing, in certain sectors, a serious shortage of nurses, particularly in hospitals in which long stay patients are looked after. I doubt whether An Bord Altranais are moving fast enough. I doubt whether there is a sufficient sense of urgency in relation to the matter of training nurses and providing them with proper conditions when they are qualified.

In his opening statement the Minister made a passing reference to the requirement that nurses should be trained in hospitals with a bed complement of not less than 300 beds. I do not know whether any change has taken place in the number of such hospitals in Ireland. I know that a couple of years ago there were 64 training schools for nurses and midwives and only 33 of them complied with the requirement of having 300 beds. I know that certain steps were taken to amalgamate a number of hospitals or bring them together so that training could be provided in a regrouping of the hospitals. I think we are dragging our feet in this regard. Perhaps I should not jump to any assumptions. I should be glad if the Minister would be good enough to let us know what progress there has been here, so that the necessary training on acceptable international standards can be given to Irish nurses.

I am also unaware what progress has been made following the march on Leinster House by our wonderful nurses some weeks ago. It is a serious reflection on our health administrators that such a march should have been provoked by a long period of inaction on the part of the Minister and his predecessors. There is little use in saying that matters are under negotiation and that therefore people should not protest but should await the outcome of the negotiations when negotiations have to go along their frustrating way for years. Human life is all too short and human suffering can be quite prolonged. It is intolerable that organisations like the Irish Nurses' Organisation or the Irish Medical Association, or the Irish Medical Union, or others, should have to put up with endless years of negotiations in order to get anything. That is the kind of thing that brings the institutions of the State into well deserved disrepute.

I would not at all attempt to justify a system which prolongs negotiations on vital working conditions to such a degree as that which the nursing and medical professions have had to endure. I would hope that the Minister might be able to give us some indition as to what changes he has in mind in relation to the working conditions of nurses. In particular I would urge upon the Minister that he should extend to nurses in temporary posts the provisions governing increments for previous service. The Department must accept that a change is taking place in the staffing of our hospitals, just as immense changes have taken place in the staffing of hospitals and similar institutions abroad. Mobility of labour will multiply in the years to come, and this mobility will become much greater if there is a rearrangement of the hospitals on the lines which the Minister has in mind.

At present many of our district and county hospitals are operating with a full complement of nurses because there are nurses residing in what are called the catchment areas of the hospitals, residing adjacent to the hospitals and giving their services on a temporary basis without immense inconvenience. If we close a number of these hospitals or reduce the nursing staffs we could easily arrive at a situation in which we would have grave difficulty in providing the necessary nursing staff for large hospitals in fewer centres. Therefore the Department and An Bord Altranais and everybody concerned with this matter will have to give serious consideration to the new structures which are necessary in the nursing profession.

I do not have to add to what I said some weeks ago regarding the working hours of nurses. Their working hours are much too long. I am not taking away from any credit due for the reduction in those hours in recent years, but the hours the nurses have to work are still too long and must be further reduced. The career structure of nurses also leaves a great deal to be desired. There is not a sufficient number of qualified nurses in the Department. I know the Minister has available to him the advice of one or two nurses in the Department, but a great deal more could be done in this field. Very correctly there has been an immense expansion in public health nursing in recent times. This is a new activity, a new discipline, which brings up special problems for consideration. Because of that the Minister would need to have a number of supervisory posts in public health nursing and I would urge upon him that he should create these posts so that the necessary management skills and the necessary supervision will be there at this time of really critical growth in this highly essential field.

I must welcome, as I have on an earlier occasion, the establishment by the Minister of a special organisational unit in his Department to examine the application of work study, occupational research and job analysis in the nursing and hospital field. This is an activity in which the nursing profession wanted to engage some years ago but I am sorry to say they were discouraged by the Department. In his public and administrative career the Minister has given plenty of evidence of his readiness to engage in work study and I hope he will obtain some useful information through the actions of this new organisational unit. While I say that, may I also plead with him to ensure that the happiness and welfare of nurses are not overlooked in any way, whatever the findings of the organisational unit may be. Happy and contented nurses are essential if we are to avoid that horrible picture which I saw illustrated in newspapers within the last week where a large number of people in a hospital had no nurses in attendance upon them but were being observed through television cameras which were transmitting pictures of the patients to some place of 50 miles distance or more.

We do not intend that.

I am sure the Minister would have no wish to find himself in that plight, but that has been done on an experimental basis in America, I should hasten to add, to see how successful or otherwise it might be; I do not think they would even approach that position themselves. However, in Scandinavia there are hospitals operating in which there is only one nurse to every 30 or 40 patients. She sits in her little cubicle and watches through television and through other metering process the condition of her patients and goes only to those who are showing a disimprovement or a need for attention. Medicine operated on that basis might bring about some improvement in relation to some physical infirmities but I could imagine it would multiply the number of people who would end up in our institutions for mental illness and, as the Minister said, that is something which must be avoided.

The provision of suitable accommodation for nurses is another aspect of our health services which has been neglected all too long. While appreciating the many demands which the Minister has on the capital resources available for the building of new hospital accommodation, I would urge upon him that the provision of suitable accommodation for our nurses should not take second place to the other demands which are made upon him.

The Mass Radiography Board as I understand it operates a service for screening people in respect of tuberculosis. Some time ago the board mentioned it was ready to operate screening processes in respect of cancer, heart ailments and a number of other diseases and conditions. I have heard with some concern that the board has been told it should confine its activities to its previous procedures in relation to tuberculosis. I should like to know from the Minister if that is so, and, if so, why it is that this very useful service is limited to the ascertainment of tubercular conditions when it could, with a considerable degree of benefit to the community, also trace possible sources of cancer, heart ailments or other conditions.

The degree of screening necessary in relation to tuberculosis is not as great as it used to be. I am not saying it is any less important that people should submit themselves to X-ray; it is just as important as ever, but the incidence of tuberculosis is not as great as it was when the mass radiography service was established. However, as the Minister has very properly pointed out in his speech today and in the statistics he circulated beforehand, the incidence of cancer and heart ailments is increasing and anything which can be done to forewarn people or their medical advisers in respect of these ailments should be encouraged and not discouraged. If the Mass Radiography Board needs more money in order to expand its services, it should be given that money.

I can see that the Minister's interest is in developing screening centres associated with hospitals and such institutions so that the general practitioner would have an association with the hospital which, perhaps, he has not got today. It will be some time before those procedures for clinical examination and screening are available, and in the meanwhile I would suggest to the Minister that the skills and equipment of the mass radiography service might well be used with great advantage to the community. If my information in this regard is not correct I shall be only too glad to hear from the Minister, but I should like if he would tell me exactly what the position is.

There is still a tremendous problem in respect of mental illness. I do not think we have moved our position in the world charts by reducing the number of people in mental hospitals by 1,424 in the last four years. We still have the highest number of our people, in proportion to our population, in mental hospitals. It is encouraging that the move is now in the right direction, but a great deal more needs to be done. I speak with some reserve on this matter, having regard to the presence of an expert in the field in Deputy Dr. Noel Browne, but he will understand that I speak as a concerned layman.

We must be disturbed by the reports which have been published recently of less than satisfactory conditions in St. Ita's Hospital at Portrane in Dublin and Our Lady's Hospital in Cork. The problems there, of course, arise to a considerable extent out of the colossal overcrowding. They are housing more people than could ever be decently housed in such accommodation. People are being housed in buildings and in an environment which are not at all acceptable to any Christian person or any kind person, if he be not a Christian, in the twentieth century. We would, therefore, urge upon the Minister that he give every assistance to the authorities concerned to relieve the accommodation pressures there and to provide proper amenities in these and other institutions.

It is only proper to say that, as far as I am aware, the authorities of both these hospitals and other hospitals have been seeking assistance from the Department of Health over the years. I think also that the Minister and his predecessors have been concerned to help them, but, again, to use the Minister's own metaphor, we must lift the carpet to see what has been swept underneath over the years. Seeing the problem there and admitting that these human cesspools of misery exist, then we can do something to cure them. I believe that if the horrible conditions which some of our mentally ill people have to suffer were brought to public attention, then there would be a clamour for the remedying of their plight.

We must be extremely grateful to the authorities of St. Patrick's Hospital and the Brothers of St. John of God for their readiness to come into the field of public health nursing of mentally ill people. I always regard it as a serious blot on our society that we operate social apartheid in respect of mental illness. It is, perhaps, an indication of the new openness of our society that mental illness is no longer regarded as something which is socially demeaning. It is now a common experience; it always was a common experience of mankind, but it is now being shared and shared properly in relation to treatment and housing. We hope this development will continue in other parts of the country.

The Dublin Health Authority have been very successful in the matter of providing hostel accommodation for people who have completed lengthy courses of treatment in institutions. I should like to comment on this matter because it is something on which I have strong views. The Minister personally need not accept this criticism because he was not the responsible Minister at the time but he should be aware of what happened. When the Dublin Health Authority first approached the Department of Health to purchase accommodation at Mount Pleasant Square, Rathmines, for the purpose of providing such a hostel they received a negative answer from the Department. The health authority had to go ahead using their own resources, which they gladly did because they knew this was for a purpose, the usefulness and humanity of which was all too apparent. If the Dublin Health Authority had not moved at that time a great opportunity and much money would have been lost because a bargain was available at that time and the health authority took advantage of it. In the new health legislation there will not be scope available for a health authority to exercise their initiative should a similar situation arise in the future. If serious mistakes are not to be made this is a clear warning for the Minister to ensure that his Department are more alert to the requirements of the community than has been the case in the past.

I do not know if I am correct in believing that the long-promised autistic unit in Cork is not yet in operation? If I am I am indeed sorry this is the case. In the Dublin region we have been obliged—not for any selfish motivation but due to pressure of the demands upon St. Loman's—to limit the accommodation there to people coming from the Dublin region. However, that creates a most unsatisfactory situation for the remainder of the country. I am aware that the provision of accommodation and beds is not the only obstable to be overcome. One can provide the best equipment and accommodation but it is useless unless one has the necessary skilled personnel available. It is essential that we remunerate on a generous scale the medical men who have the skills necessary to bring happiness and contentment to many of our people and by so doing can fulfil a task which we, as a society, are obliged to render. However, it will also confer immense economic benefit on the community because the less sick and handicapped people there are, the better off is the community in the long run from the social, moral, economic and cultural standpoints.

I am pleased to see that the Minister has listed additional care for the aged among his priorities. Before I deal with the care of our senior citizens, I should like to mention how disappointing it is to observe that our voluntary hospitals are still not doing their share in the care of geriatric patients. It is essential that, as our mental hospitals have now been desegregated, our general hospitals would not in the future have an age segregation under which they refuse to accept or else expel people who are elderly. St. Kevin's Hospital in Dublin has a total bed complement of 1,286. The number of beds officially available for geriatric patients is 286 but the number of geriatric cases can frequently rise up to the 700 mark. This is due to the fact that voluntary hospitals do not want elderly people.

I am glad to see that the Minister is providing for an immense increase in the amount of money to be expended on health education and perhaps some of this money could usefully be spent in convincing our society and, in particular, the administrators in our private and voluntary hospitals that a person is not about to die simply because he is 50, 60 or 70 years of age. In the statistics the Minister circulated it is pointed out that the life expectancy of a man at the age of 50 years is 23½ years and of a woman is 26¼ years. When one sees the behaviour of some medical people one would think that a person has come to the end of his useful life on reaching the age of 60 or 65 years.

Some years ago I came across the case of a man of 82 years who was knocked off his bicycle. On the back of the bicycle he was carrying two sacks of potatoes he had dug from three plots—this person was an extremely healthy man. However, when the insurance company was approached to pay compensation they were inclined to treat the person concerned as having a life expectancy of only six months. They were almost tempted to claim compensation from the cyclist on behalf of the motorist on the grounds that he should not have been there at all. I was pleasantly surprised to discover that his life expectancy was about 4½ years. Having reached the age of 82 years and having overcome the many threats to his physical and mental well-being he had shown himself to be a person of immense stamina. We need greater readiness from all in our community, including those who own and operate voluntary hospitals, to accept that people can and must lead useful lives even in old age. If this were done there would be a proper distribution of responsibility for the care of the aged in hospitals.

We welcome the Minister's remarks regarding the provision of day centres and the increase from £75,000 to £100,000 for assistance to voluntary bodies caring for the aged. If I now criticise the Minister I am sure he will understand it is because the Minister's own effort in this regard is praiseworthy. However, it pinpoints the justification of a complaint which Deputies on all sides of the House and which public authorities have made for many years past. The State accepts no responsibility whatsoever for the payment of any money under public assistance. Some 70 per cent of the increase in public assistance in Dublin over the last four years has been in respect of providing aids and comforts for old people. The way in which the Minister could give really practical help to the aged is by accepting responsibility for a much larger share of the cost of assisting these people. Here, we come up against the decadeold separation between the Department of Health and the Department of Social Welfare, each arguing that the responsibility lies with the other Department. An elderly person who is sick, lonely, unable to feed himself or herself, has not the necessary medical attention, has no fuel, and so forth, is not concerned with ministerial responsibility, bureaucratic rivalry or administrative complexities. The Minister has indicated his tremendous personal concern for the provision of better services for elderly people. Would he go a great deal further than he has gone? Apart from the humanitarian aspect altogether, money spent on elderly people outside of institutions is money well spent because it reduces the ultimate demand on institutional services and thereby saves the economy.

I was delighted to learn that the Minister is thinking of establishing units to house 40 or 50 elderly people who would have their own rooms but would otherwise live in community. This is something which could be accelerated. This is something which would ensure that our elderly citizens would end their days as useful citizens and not as pitiful vegetables.

One of the great benefits the elderly have enjoyed in recent times is the provision of free transport. This is related to old age pensioners. I am thinking now of a case in which an elderly person fell into bad health; she could no longer ride her bicycle and she could not afford to travel from Rathmines to Santry to visit a widowed sister. Even though the sisters lived apart they met frequently. This unfortunate woman could not get free transport because she was not a pensioner within the meaning of the Act. She is now being maintained in St. Kevin's at public expense. The fact that she could no longer visit her sister was a contributory factor to her subsequent ill-health. This could have been avoided had there been a little more flexibility. This service is unlikely to be abused. I cannot imagine any elderly person flying around in public transport just for the fun of it. I am sure elderly people would soon get tired of that kind of recreation.

The failure of the Minister for Social Welfare to handle the problem has imposed a burden on health costs. Free transport should be available for disabled persons. At present two categories of disabled persons are in receipt of free transport from public sources, those who receive disablement benefit and those who get disablement assistance from the health authority. Free transport for such people could be of very great benefit and, as the Minister said, anything which contributes to the maintenance of contented beings in the community is something we should all strive to achieve. This is one area in which the Minister could exercise some activity.

Earlier I expressed my disappointment at the slowness of negotiations between the Minister and the medical and nursing professions. May I now make a further complaint about slowness in negotiations in relation to the settlement of terms for the retail pharmacists so that they can be brought into the public service? It is at least three years since the Minister for Health assured the House that he was actively negotiating with the pharmacists in order to bring them within the public health service. At that time there was no indication given to the pharmacists, or anybody else, that their involvement in the health services would have to await the implementation of the Health Act. The worst part of the Minister's statement today was his declaration that he could not complete negotiations with the retail pharmacists until the 12th round of wage increases had worked its way through the economy and the effect of such wage increases on the economy had become known. By that time there will be some other economic or financial process affecting the country. The Budget could have an effect upon negotiations. So could some international crisis. Some activity in the import/export market could have an effect on the economy and any one of these could have a critical effect upon the negotiations with the retail pharmacists, the wholesale pharmacists, the Pharmaceutical Society and the Wholesale Drug Federation and all the other bodies with which the Minister is negotiating at the moment.

I urge the Minister to complete these negotiations with the minimum of delay so that retail pharmacists can be brought within the scope of the public health services. This is necessary even if the Health Act, 1970, had never been passed. The delays in securing prescriptions is appalling. Not only does the delay add to the burden of personal misery and, perhaps, risk but it also adds considerably to the length of time it takes to cure those concerned of their infirmities. Nothing should be done to delay the involvement of the entire pharmaceutical trade in the health services.

I was glad to note the Minister is receiving co-operation from the health authorities in Northern Ireland and that the Department proposes to use computers for the purpose of determining the appropriate prices to be charged. I would urge that the Minister would apply his activity in this field not merely to prescriptions which may be purchased through or in connection with the public health services but that similar action would be taken by him in relation to the whole price structure of the pharmaceutical trade because, while deploring and recognising the fact that turnover tax applies to human medicines although not to veterinary medicines and accepting that there may be other cost items which do not apply to pharmaceutical supplies in other countries, one must continue to worry considerably at the colossal differentiation which not infrequently exists between the prices of medicines here and in Britain or Northern Ireland. It is extremely hard to justify these prices and I would suggest that here is a field in which the Minister for Health and, perhaps, the Minister for Industry and Commerce could carry out considerable research with public benefit because the reality as distinct from the theory— and a great deal of the Minister's statement today was nice pleasant theorising—the reality is that many people in Ireland postpone taking or neglect to take prescriptions because of their cost or, what is sometimes worse, they take some of what is prescribed for them but do not purchase the balance and by so doing may, perhaps, aggravate their condition rather than relieve it.

All that can be said whether people are within or without the eligibility levels which the Minister may have in mind in respect of the public health services. Therefore, as it affects the whole community, I would urge upon the Minister to take action in this field. I do not know who is getting the profits at the moment, who is cleaning up on it but, certainly, I know many people are unable to afford the prescriptions which they should otherwise be taking. I know there is a provision within the old law and there will be provision in the new law whereby such people can get assistance from health authorities if the provision of drugs or medicines can become an undue burden upon the family. That is an acceptable and workable and to a degree a successful system in respect of long-term medicines but the kind of thing that I am thinking of which frequently arises is where there are two or three or four of the family down with flu or some other ailment and require expensive drugs or medicines, they quite frequently just do not take them or they may get one bottle for four persons where four bottles should be obtained. That bottle is shared around and all it does is to leave the infection in a state of suspense until it breaks out to a worse extent later on.

The Department some years ago introduced a commendable scheme for the provision of free medical supplies for diabetics. I was interested to note from the Minister's figures that the cost of the scheme works out at £64,000 a year—a mere pittance in relation to total health costs but of colossal importance to people who were afflicted with diabetes. It has allowed such people to lead the kind of life which other people are able to enjoy. Until then they had to expend a considerable proportion of their income in the provision of insulin, and so forth. Now they are able to lead lives the equal of anyone else. For that again we commend the Minister's predecessor who introduced this scheme.

The figure of £64,000 is what the Minister might call a nugatory expenditure. It is certainly nugatory compared with the colossal benefit it has conferred upon diabetics. Might I urge upon the Minister, the door having been opened in relation to expenditure of that kind, that free drugs would be provided irrespective of means to all cases of epilepsy? There are, I know, a large number of epileptics already receiving benefit under our existing law but it would not greatly burden the Exchequer if the balance of such people were to receive the necessary drugs. I would urge upon the Minister that he would do this.

It may well be that under the new Act the Minister will use the powers available to him to prescribe that as one of the conditions which would entitle a person to get adequate drugs and medicines free of charge and if that will be so, I shall be delighted to hear it.

One sometimes wonders at the activities conducted by one Department instead of another. One case that is rather bewildering is to find that it is the Department of Health which is responsible for payments to boarded out children. Here, we really have scandalous payments for foster children. On the latest figures, one authority is paying 14s a week and the highest that is being paid is £2 10s a week. It is no answer for the Minister to say that it is in the discretion and power of any local authority or health authority to fix its own figures for this item of expenditure. If it is and the Minister finds they are paying inadequate sums, as I believe some of them are, then I think the Minister if he has not the power should seek the power and if he has the power should use whatever power is available to him to ensure that adequate payments are made in respect of boarded out children.

We are investigating that question with a view to rationalising the enormous differentials.

Good. I am glad to hear that the Minister is investigating it but I would urge him not only to examine the question of rationalisation but also to ensure that the ceiling is raised so that adequate sums will be paid because if they are not there is the danger of abuse and in this day and age when children ought to be retained in school to an older age than formerly it is important that we should not be providing economic forces to urge people to send children out unnecessarily to work at a tender age. That can happen if the payments are not adequate. I know the Dublin Health Authority takes particular care to ensure that children who are qualified to do so get the best available education and many children have had conferred upon them through the Dublin Health Authority education which, perhaps, might not have been made available to them if they had never been orphaned. I would not regard that as sufficient compensation for the loss of one's parents but it is something of which we should take particular note and encourage similar activity on the part of other health authorities throughout the country.

I can sympathise with the Minister in the tremendous problems he has in receiving and evaluating the representations being made to him about the closure of small county and district hospitals but I sense a certain impatience and resentment on the part of the Minister in his opening statement today. The Minister makes it perfectly clear that he will not at all concern himself with the economic contribution which a hospital may be making to the local community. The Minister has made it clear that his concern is solely the question of the provision of adequate hospital, medical, surgical and consultant services for the sick.

The Minister is to be thanked for his frankness and his honesty but I do not think the other consideration should be overlooked. There are very few decisions a Minister is called upon to take which do not have some element of social cost in them. It is not good enough to reject in toto all question of the social consequences of ministerial decisions; these must be balanced. The social cost benefit must be assessed and one must then consider whether the apparent medical benefit is commensurate with the loss, inconvenience and all the other factors which will result to a community if a small hospital is closed.

I notice from the figures which the Minister was kind enough to circulate that county hospitals have an occupancy rate of 82.7 per cent and district hospitals have an occupancy rate of 73.3 per cent. I am not quite certain what the Minister's thinking was on this. I think he was arguing on the one hand that small hospitals lead to an excessive rate of occupation and that removing people from their own locality to a county hospital would ensure they would get out of hospital more quickly in order to get back to their own environment. That may be so in some cases but not all. The truth is that most people do not leave hospital until they are encouraged to do so by their medical advisers. I do not think we can readily brush aside the social and economic considerations responsible for such a high rate of occupancy in the local hospitals. While the Minister may have his own ministerial and administrative decisions to take, I would ask him not to overlook the humanities of the matter and totally reject, as he has, the economic and social considerations in a community.

The Minister assumes—I hope he is right—an economic and urban growth rate which will be more than sufficient to compensate any community for the loss of its own county or district hospital. That is a sweeping statement. I hope and pray the Minister will be justified in time, and, of course, we will all work towards that end. But it would be totally wrong to proceed on that basis because some of these hospitals are situated in areas which are unlikely to have industrial and urban expansion at a rate equivalent to that operating in the rest of the country and for that reason some hospitals must be maintained in remote areas. I realise we must anticipate the situation which has occurred elsewhere where it has become difficult to get surgeons and other consultants for some hospitals in remote places which are not adequately staffed. But, just as we have to maintain a hospital on the Aran Islands today, although economically I am quite certain it is not viable, we will have to see to it that as the richer centres grow the remote areas are not neglected.

I know this is a question of cost and the Minister is right to be concerned with cost but we must not overlook the social consequences of any decisions which are taken, particularly decisions regarding sick people who require the very best of care reasonably available. If we withdraw too much from the scattered areas the great danger is that care will not be available when it is necessary. The Minister should move cautiously in this regard. Of course, unless the Minister gets the growth rate that he is talking about, it may well be that he will have to go slower than the rate at which his own intentions would otherwise propel him because the capital required to carry out all that is contained in the FitzGerald Report in the next 20 years will simply not be available unless our growth rate is two or three times greater than that forecast in the most optimistic estimates to date.

I can understand why the Minister is saying to people that there is no point in continuing with representations at the moment because it may be some time before anything further is done. I think this arises from ministerial impatience of having to listen to people, but it is a great thing to be able to listen and record so that one gets a full brief. I appreciate the Minister will be bringing proposals before the House in relation to the regionalisation of hospitals and so on but if the Minister is not fully briefed there is not much likelihood of anyone else being so. The Minister should receive all such representations. It is the essence of democracy to hear complaints and a Government which will not hear complaints is an unsound one. The Minister should qualify what he has said or else make it clear that he will listen with a sympathetic ear to all that has been said and that the social factors will not be rejected out of hand.

I have certainly listened. The first consideration is the saving of life and that is social, is it not? The second consideration is finding the staff.

I agree with the Minister, but you can save a life and kill a community. You might increase your psychological pressures and all the other pressures which the Minister is worried about in relation to mental illness if you start withdrawing essential health services and hospital services. Doctors may differ on this matter and patients might die as a consequence. I do not want to enter into any detailed controversy on this; we shall have another opportunity on which to do that. The Minister has now said that he is prepared to listen but I think he is reluctant to do so.

I have spoken about outpatient departments in hospitals before. I do not think we have advanced as much as we ought in relation to outpatient departments in the larger urban hospitals. I notice from the circulated figures that one of the Dublin hospitals has as many as 730 patients in its outpatients department per day and that figure is based on operating a seven-day week. If a five-day week was operated one would find that this hospital is supposed to be handling, satisfactorily, 1,000 people per day, and this is apart from accidents. Such an outpatient department does not exist and I would urge the Minister to fulfil the promise made by his predecessor to reorganise all outpatient departments and provide them in all public authority hospitals as well as what we call voluntary hospitals. A great deal needs to be done in this field so that a great deal of hardship to people can be avoided.

We should not tolerate for yet another year a system under which people are required to attend at 8.30 or 9 o'clock in outpatient departments in hospitals and still be there unattended at 2, 3 and 4 o'clock in the afternoon. I am quite well aware of the many pressures on surgeons' time and the time of other skilled people who attend to look after the sick and the injured in outpatient departments. I am not making little of their problems. We understand the many pressures and anxieties which make it impossible for any of us to be in three or four places at the one time and the blame which frequently attaches to us because we are not there. Allowing for all that, there is still plenty of scope within the operation of outpatient departments in all hospitals to have more humane systems operating so that the sick and invalided and worried are not required to attend for many hours before receiving utterly inadequate attention.

In that regard also the Department of Health must come to the assistance of hospitals. I think there is now a greater readiness than there used to be to provide money to build satisfactory accommodation for outpatient departments. Up to some years ago the out-patient departments used to be in the outhouses, in the buildings which were not acceptable for any other use. Having regard to the large number of people now availing of them, out-patient departments need to be upgraded and provided with ample accommodation for the medical and nursing people attending in them and also for the patients themselves.

I was glad to note that the Elm Park Hospital is well under way, that there are already some people in hospital there and that it is hoped to have it fully functional before the end of the year. In Elm Park, I understand, it is also proposed to have a new school for radiographers. I would urge upon the Minister to have a second school established as quickly as possible because there is a serious shortage of radiographers at present and unless something radical is done about it we could easily find ourselves in one of those bottlenecks that the Minister says, quite properly, he is anxious to avoid in our health services.

Finally, I want to say that the Minister's greatest omission is that he has said nothing whatsoever about an insurance scheme for health services. We have been assured for six or seven years past that the Government had arrived at the position of having no objection in principle to an insurance scheme but that they were examining its feasibility. We were told in the Third Programme for Economic and Social Development that the matter was under active consideration by the Government. In the White Paper on the future development of the health services published in January, 1966, we were told that the Government were examining new sources of revenue for the health services and in March, 1968, the then Minister said here in the House that new sources of financing the health services in future were being considered by the Government and proposals would shortly be submitted to the Government. Yet we are in the position that our health services and their future development depend on revenue, 41 per cent of which comes from rates and 59 per cent from taxes. The health services are in competition with every other service provided by the State and, as a result, health services are down at the end of the queue. If the State had held health costs on rates at the same level as they were in 1966, when that famous White Paper was published, rates would now be as much as 15/- in the £ less and the State would be accepting responsibility for about 75 per cent of total health costs instead of a figure which the Minister says is approximately 60 per cent. Those figures, of course, do not take account of the growing burden of public assistance charges which fall entirely on the rates. To an increasing extent the rates have to be raided in order to provide the necessary medical assistance and care for aged people in the community.

I feel the Minister has failed badly under that head. I am sorry to have to say it because the Minister is a sincere man. I know he is doing his best. He is trying to overcome the tremendous backlog of inactivity in his Department. He has challenging new ideas and he is endeavouring to develop them with the available money, but we honestly believe that a great mistake has been made in not changing the whole basis of financing the health services at this time of great change. If it were done the Minister would probably find that a large part of his burden would be eased.

On that account I must say that, while I am grateful to the Minister for his most helpful introductory speech. I am sorely disappointed that the issue which has been most debated in this House ever since I came here has been totally avoided by him. I would hope that before the end of the debate we might hear something from the Minister on this very challenging aspect of the health services.

I should like to join with Deputy Ryan in thanking the Minister for the statistical information which he circulated to us in advance of the debate and which was very helpful indeed, extraordinarily meticulous and valuable to us in attempting to speak to some extent on this important Estimate. I should like also to express my appreciation of his opening speech, an extraordinarily lengthy one, a wide ranging, frank appraisal of the important and formidable job which he has taken on as Minister for Health. If we take those 47 pages of the Minister's brief, mostly of good and sound proposals, and add them to the 130 pages of the booklet on the care of the aged, between the two of them we can get some sort of an assessment of not only what has to be done in relation to the sick and aged in Ireland but, more important to me, what has not been done over the best part of half a century of native Government.

I suspect, and I do not expect the Minister to agree with me, that the Minister is probably about as shocked as the rest of us are—he is new to this Department and nothing I say is meant to reflect on him at all—by the disclosures of his brief and of this other booklet on the care of the aged.

I will simply attempt to be constructively helpful to the Minister because I believe that, whether he succeeds or not, he would like to succeed. I think he probably intends to succeed in putting to right many of the various defects he has outlined here this evening.

I should like to take issue with him, first of all, on an old subject of mine which I have dealt with for many years now. It is the problem of cigarette smoking. It may seem a relatively small item to begin with but there is an attitude in the Minister's handling of it which I think should be pointed out to him. He seems to me to be attempting to dodge the issue by including cigarette smoking and coronary diseases in the same category and he discusses both by saying that you can only continue by every means at our disposal to encourage people to stop cigarette smoking in their own interests.

In regard to coronary heart disease and cigarette smoking I ask the Minister to approach this problem with a greater measure of honesty and frankness than he has done up to now. There is a great difference between the two. In relation to one, medical people believe that there are certain pre-disposing factors which probably lead to the development of coronary diseases, but there is no certainty, merely presumption. Indeed, there is a great debate going on at the moment. The president of the NFA resented the suggestion about high fat diet contents and he brought two distinguished people from the States and others to support him in his contention that butter fats and so on are not that important. We had another distinguished authority, Dr. Risteárd Mulcahy, a very distinguished physician. There is a genuine, honest conflict of opinion and I personally do not know which is right.

All I am saying is that there is a doubt about the pathogenesis of this disease. That, of course, is why the Minister is collaborating in the way he is in the research project which is being carried out here at the present to which I wish every success.

In relation to cigarette smoking I do not like to appear to be an avuncular kill-joy, if that is the correct expression, but it is a very serious question. Anybody who has seen an individual dying of lung cancer—the patient suffocates to death, a terrifying experience and, I am sure, terrifying for the person watching as well—must take it very seriously indeed. The truth is that there is no doubt at all about the origin of lung cancer—that nine out of ten cases are caused by heavy cigarette smoking.

I have been talking about this since 1957 when a very intelligent and fine piece of work by a couple of GPs in England pointed to the possibility that this might be so and various authorities here and in the US followed up these speculative investigations and now we have the position where there is absolutely no doubt that heavy cigarette smoking causes lung cancer. May I say I speak as a former heavy cigarette smoker not for any reason except just to accentuate the point that most of us in the medical profession have discontinued cigarette smoking because we are convinced of the great danger associated with it of incurring this terrible disease.

The result of this decision by the medical profession is particularly interesting because since doctors stopped smoking—they were terrified into it: they are not better people, stronger-minded people, it is as simple as that—the death rate among doctors from lung cancer has been only two-fifths of the national rate in Great Britain. That in itself is one very significant indicator of the importance of attempting to help people to stop smoking cigarettes. Pipe smoking, as the Minister does, or an occasional cigar, as I do when I can afford it— Cuban cigars from Havana, and I hope I will not be anathematised for this—is all right but cigarette smoking is out.

I know the Minister's difficulty. It is a revenue problem. I do not think an intelligent person like the Minister has any doubts that in allowing cigarette advertising in newspapers and on television he is encouraging people to smoke. He knows this is tolerating something which he in conscience should not continue to tolerate. I am quite sure that intellectually he is convinced, and I suggest that he has a serious moral responsibility in this.

I know the Minister for Finance will be very angry if the Minister for Health goes to him and says: "Something must be done about this trade in cigarettes because I am convinced it is a bad thing and that it is a costly thing". Nine out of ten lung cancer deaths are caused by cigarette smoking, three out of four chronic bronchitis cases are caused by cigarette smoking and one out of four coronary diseases are believed to be caused by it, and these three conditions together, caused by cigarette smoking, are responsible for 20 working days lost to the community compared with one lost through industrial disputes.

I think that from the community's point of view, from the point of view of the Minister for Finance, of society and of industry, these are very significant and important facts. It is a terribly costly luxury from the point of view of the Minister for Finance, and from the purely humanitarian point of view it causes untold misery and tragedy.

I have not much regard for the American way of life. I have great regard for many Americans, but do not take me, please, as condemning the American people. However, I have been struck by the fact that an industry such as the American tobacco industry has not been able to stop the American surgeon general having the fact printed on cigarette packets that they are dangerous to health and so on.

It is a great achievement for the American people that they have taken this decision and that they have tried to counteract to some extent the very insidious, very clever and very talented advertising campaign which is directed towards encouraging people to smoke cigarettes when they knew that the basic industry of the country was at risk. People continue to smoke cigarettes even though they know that in many cases this will result in painful deaths.

I understand that contrary to what the Minister told me the other day in reply to a Parliamentary Question, this has helped to reduce the number of cigarettes being smoked. I do not know whether this is so but it is my opinion that one would have to do very much more than simply print a warning on the cigarette packets. One would have to stop the advertising on television and in the newspapers and then go over to a positive advertising programme. It is no good saying that advertising does not encourage people to smoke cigarettes. Of course it does. If it did not companies would not spend such amounts of money on advertising. If advertising is useful in altering people's attitudes, consumption pattern and so on this costly superstructure of advertising should be dismantled. Of course, if an advertising campaign were to be launched to help people stop cigarette smoking and change over to a pipe or to cheroots which are less damaging and less dangerous to life, it would be a very costly business. The British, apparently, intend curbing cigarette advertising and I understand they intend to discontinue it altogether. They have already done so on television and there is a positive programme by local authorities to publicise the danger of contracting lung cancer as a result of this habit.

An effort was made here in this direction but it was concentrated on the young people. However, this effort was fallacious and relatively useless as a recent survey indicates. The idea was that by trying to prevent young people from smoking cigarettes we would reduce cigarette consumption. This idea ignores the fact that the whole process of development of an individual is largely the result of imitation of the adults around him. If a child sees his parents smoking cigarettes he will think that this is a permissible habit, that it is a good thing and, therefore, he himself will develop the same habit unless he is an exceptional child. This, then, is not the solution to the problem. The Minister will have to concentrate first of all on the adults. They must be encouraged to discontinue cigarette smoking. They cannot be prevented from smoking cigarettes and there is no good forbidding the habit but they must be educated in some way or other into realising the seriousness of this form of addiction.

Many of my medical colleagues who smoke cigarettes will not accept the definition of this habit as an addiction. They usually refer to it as drug dependence which is a different thing. They do not like to be referred to as addicts and so we have this euphemism of "drug dependence" for "addiction".

The total revenue for all tobacco has risen from £13.5 million in 1950 to £47.5 million in 1969. It is obvious that the Minister is in a spot in relation to this matter. If the Minister for Health succeeds in cutting down the consumption of cigarettes, the Minister for Finance will find himself in trouble. It is as simple as that and I do not believe there is anything else to it. It is a question of tax revenue but it is a problem which the Government must face. It is a question of whether they consider that they have a moral responsibility in this regard. Many other countries find themselves in this type of situation.

There is a suggestion that at the moment somebody is vetting advertisements. The Minister must realise that he is exposed, and legitimately exposed, in this respect to charges of hypocrisy. For instance, when it was decided recently that cyclamates were bad, he brought in the necessary legislation to stop their use in drinks. The Minister was intelligent enough, perceptive enough and conscientious enough to take this step. Similarly, in relation to drug abuse about which we hear so much. However, it is debatable, as Dr. Risteárd Mulcahy said the other day, whether hashish should be prohibited completely. I cannot say whether I believe it should or should not be but I am inclined to believe that it should not be regarded in the same category as hard drugs. We know there are a number of countries in which hashish is smoked extensively without any great disaster resulting to the community, at least without any disaster that is more serious than the disasters of lung cancer, chronic bronchitis or coronary heart disease. We should try to keep these matters in perspective. It is debatable whether the Minister should have acted as rigidly as he did. I have cared for a number of drug addicts from time to time and most of them believe that there is no necessity to go from soft drugs to hard ones. However, if we leave aside the rights and wrongs of that decision, it is significant that in relation to the cyclamates, in relation to hashish and in relation to the amphetamines the Minister had no hesitation in bringing in the necessary regulations to curb their use although he knows the terrifying figures of deaths in Ireland from lung cancer.

I was talking a minute ago about British figures. Here are the Minister's own figures in relation to lung cancer. Since 1950 to 1968, the last available figures: 1950—298, just about 300; 1968—971, nearly a thousand. From 300 to 1,000. I know he can make an answer about certification in 1950, and so on: I do not care. I think that jump in figures, accepting defective certification in 1950, is a very serious development. By the way, certification was not too bad. It was around that time that we set up the chest diagnostic services. We had fine surgeons, and so on, with X-rays and operations. It was not a bad time, really, for that particular condition. This jump in figures is very alarming in the light of the avoidable hardship these figures represent in human suffering.

For chronic bronchitis, the figure has jumped from 400 to 1,400. For coronary heart disease, the figure has jumped from 1,700 to just under 6,000. The Minister cannot just dimiss those figures. I believe he is too conscientious just to dismiss them with the phrase used in his opening speech: "All that a Minister for Health can do in this situation is to continue and, where possible, intensify health education..." There is sweet damn-all propaganda beamed to the public at the moment in this connection. On the contrary, in relation to cigarette smoking, the propaganda beamed on the public continually through the television, through the newspapers, is to smoke cigarettes and to go on smoking more and more cigarettes.

I would ask the Minister to reconsider that part of his responsibility as Minister for Health. All of his predecessors have dodged the issue; they have all refused to deal with it at all. To use his own metaphor, they have all brushed it under the carpet. I do not think he can go on doing it in view of the fact that countries who can do so are taking action in regard to it. It is intellectually dishonest and morally indefensible to go on allowing this situation. The case which I am sure he would make against, say, opium smoking or morphia or most of the drugs, certainly the soft ones, can be made with much greater force against the smoking of cigarettes. The Minister is not being frank with us. He is failing in his responsibility to the community, as Minister for Health, in refusing to take serious action in relation to this matter.

The very impressive figures in regard to diphtheria and poliomyelitis can be attributed to preventive medicine—the free vaccination scheme. The diphtheria figures for 1968 and 1969—nil, nil— are magnificent. Then we see the wonderful figures in relation to poliomyelitis for 1966, 1967, 1968 and 1969 —nil, nil, nil, nil. Just as the Minister who introduced the free vaccination scheme for poliomyelitis discharged his responsibility to prevent suffering, and similarly in relation to diphtheria by eliminating it as a disease, this Minister for Health has the same responsibility for the elimination of any other preventable disease. We know, from the figures, that, taking the right steps, it is possible to prevent nine out of ten —it is said—lung cancers.

Like Deputy Ryan, I am shocked at the high gastro-enteritis figures. I think they reflect the bad home conditions of many young families—lack of clean milk and food and overcrowding. Admittedly, that is not the Minister's Department so there is little he can do about it except to ask his colleague in the Department of Local Government to do something about it.

The figures for venereal disease have increased from 249 to 383; syphilis, from 64 to 99. I wonder if those are the real figures. Quite a lot of this disease is treated by private practitioners who may not bother to notify the fact that it has occured. It is a strange phenomenon in its own way, I suppose. Deputy Moran, Minister for Justice, remarked recently he was not sure whether it was caused more by prostitution or by people who were not prostitutes who simply got the disease and passed it on. The interesting thing is that prostitution has not really dropped. In many societies, many of us believed it was due to the social economic pressures of one kind or another. Apparently that is not so. It still persists in spite of the fact that quite a number of these people who become prostitutes need not do so. One of the obvious preventatives is the one accepted by any armed forces anywhere, namely, the use of contraceptives. I have had prostitutes as patients in St. Brendan's. The general feeling, talking with them, is that contraceptive appliances are not available and it is one of the most obvious ways of trying to avoid the spread of venereal disease in any society at all. That is another matter which the Minister may care to think about.

I do not suppose we need bother about this discrepancy in the medical cards. This does not matter if the Minister is to have a uniform scheme. I do not suppose there is much point in dealing with it. It varies in the different counties from 15 to 50 per cent. I hope this will be changed under the Minister's new scheme.

Deputy Ryan referred to the free diabetes scheme. I wonder is the £64,000 which he mentioned part of the £97,000 for the cost of drugs supplied by health authorities. The number of people assisted was 7,800. Is the £64,000 for the free diabetes scheme to be included in the £97,000? I must say I think that is a pittance.

That is a separate figure. It is tucked away somewhere else.

I see. I have been approached frequently by white collar workers who were anxious to try to get help under the provision in the Health Act whereby the health authority were allowed to help that type of person when the bills were exorbitant. I am afraid I never really found it particularly satisfactory. By the time one got the evidence and persuaded the health authority and the medical officer for health and so on, the person had lost interest in the whole proceedings. It does not really exist as a serious scheme, I am afraid. It is there as an earnest of the then Minister's wish to help that type of person but I do not think it is operated in a serious way.

Even at this stage I would join with Deputy Ryan in asking the Minister why it is that no proposals are put forward by him in relation to the provision of some kind of general medical scheme for the white collar worker who is paying all the rates and all the taxes and who is not covered by the Voluntary Health Insurance Scheme which, of course, has many defects. The most important of all probably is that it does not give a general practitioner domiciliary service. Even more important than the doctor's fee, it does not pay for the chemist's bill. I hope the Minister will tell us whether he is giving serious consideration to the provision of some scheme.

As the Minister knows, I favour the British no means test health scheme but, without any shadow of doubt, I would welcome the introduction even of an insurance scheme for this kind of person if the Minister would consider bringing it into operation.

In his opening statement the Minister discussed the FitzGerald and the Todd Reports more or less together —quite rightly because of their implications—and bed usage is one of the things he referred to. I wonder has he any explanation for the St. Kevin's Hospital bed usage: medical, 67.7 days average duration stay; Galway Regional, 20; Limerick General, 10; Limerick Maternity, 7—that is a different hospital—Ardkeen, 13; Finbarr's, Cork, 17. What is the explanation for this extraordinarily high figure of 67.7 days average duration of stay in St. Kevin's Hospital? The surgical figure, too, appears to me at any rate to be disproportionately high. Something appears to be very wrong. The Minister may have a good explanation but it seems to me to be very wrong that on the surgical side in a number of local authority hospitals it is 22.7, 12, 8.9, 8.4, and 14.6 in Cork. What is happening in St. Kevin's? Why is there this great delay or why is there this apparently long stay by medical and surgical patients in St. Kevin's Hospital? I presume this does not include the geriatric figure, which is 117 and which I can understand. On the medical side why is it as high as 67.7 days average stay? Would the Minister give us some answer to that.

There is one other question in relation to the hospitals. The Minister gave us a number of figures concerning the old sanatoria: Merlyn Park, Sarsfield Court and James Connolly. We do not appear to have any figures about the daily bed occupancy in relation to the non-surgical or cardiological non-TB beds. What I want to know is what is happening in relation to the beds in these sanatoria? They are enormous places. They are very beautiful places. The accommodation is of very high quality. In Cork city, for instance, there appears to be a very serious problem in the local mental hospital. What is holding up the use of these places for geriatric cases, mental handicap or psychiatric cases or whatever they like?

I cannot see why it is necessary to keep these places on as sanatoria in view of the decreasing incidence of tuberculosis. With the general approach now towards domiciliary care, which is almost universally accepted for tuberculosis nowadays, there is really no great need to put these people in hospital. They can carry on working and get injections. I wonder could the Minister tell us what is happening in relation to these enormous places? What alternative uses will they be put to? I wonder would the Minister consider setting up some sort of committee on bed usage particularly in the Dublin area? I do not know much about Cork but it appears to me that there is some need for an objective committee to examine the use of these beds and see whether we are getting value for money.

In Sarsfield Court we are told there are about 120 beds divided up in various ways. What is happening to the rest of the beds? What is the bed occupancy? What are the vacancies in these institutions and could they not be used? Could we not have some attempt to expedite the transfer of patients from some of our very overcrowded hospitals, particularly the mental hospitals and the places in which we keep our old people—some of them are county homes—to these institutions.

Other very interesting figures provided by the Minister were in relation to the district and auxiliary mental hospitals. We have the patients on the register on 31st December, and so on. He is disappointed, as he has a right to be, at the fact that there has not been a particularly noticeable reduction. Here we are on dangerous ground in a way, but recommendations were made as far back as 1966 by the commission on mental illness and there has been only a relatively small reduction in the ten-year period. Some have been very good or reasonably good but some of them seem not to be changing anything like as rapidly as they should be changing if we were switching across to the communitytype service, if we were adopting the open door policy, the removal of the walls, attempting to treat the individual in the community.

We do not seem to be getting that at all. On the contrary, there has been an extraordinary development—I wonder if the Minister has an explanation for it—that while there has not been a very great reduction in the number of beds occupied in our mental hospitals, there has been an enormous increase, which is very welcome, indeed, in the psychiatric clinic attendances. There is a very significant increase in some areas; some are better than others. You would imagine, with this increase in clinic attendances, there would be a very dramatic reduction in the number of bed occupancies. St. Brigid's, Ardee, has gone from 146 to 5,300 attendances; our own St. Brendan's from 5,000 to 30,000; Our Lady's, Cork, from 8,000 to 15,000.

Why is there this overcrowding? Are more people coming for psychiatric help? Is this a sort of Parkinson's Law, the more services we provide the more people who will come and make use of them? There has not been a dramatic reduction in St. Brendan's; we have reduced by only about 700, and yet the attendances at clinics have gone from 5,000 to 30,000. Should we not be getting a more serious reduction of the number of people in hospitals? Could the Minister say whether the reduction in St. Brendan's of 3,767 to 3,093 represents a decrease in the number of psychiatric cases or a decrease in the number of people who have been reclassified as geriatric cases?

In passing let me say that recently there was conciliation and arbitration in relation to pay and conditions in the psychiatric service and that there was an extra award, a sort of bonus payment, to the individual who has the most patients: 1,000 plus gets a salary greater than, say, 1,000 or fewer. These are not the correct figures but they illustrate the point. If the Minister accepts this kind of differential in relation to the very big hospitals he is going against his broad policy decision in regard to encouraging hospitals to develop community services and preventive medical services to keep people out of hospitals and reduce the size of hospitals. This is a point he might like to think about. It may lead to the perpetuation of the individual who says: "Keep 1,200 and I will get £300 a year more". I am sorry for sounding so mercenary, but this is something which may work against the Minister's own policy of trying to reduce the size of the mental hospital population.

I welcome the voluntary hospitals superannuation scheme, which is long overdue. This now removes any difference there was between the local authority medical employee and the so-called voluntary hospital employee. Again, like Deputy Ryan, I think we must examine much more seriously this whole concept of the voluntary hospital. The Minister is a very conservative man indeed—I am not using that expression in its pejorative sense but simply as a matter of fact—and I was delighted to note that he became slightly irascible towards the end of his speech with the voluntary hospitals that they would be asked to do something about taking part in an examination of the administrative services. This is very badly needed, and he said that if they did not collaborate he would be inclined to stop their deficit payments. I hope I am not misrepresenting what the Minister said. I was glad to notice that even in his very moderate way he was beginning if not to thump the table at least to tap the table at these people and make them come into the seventies and realise that we are all local authority employees. There is no such thing as a voluntary hospital any more. Even though various Protestant and Catholic hospitals claimed the money they had was private money, most of it came from the public. Whether that was true or not, the truth now is that, through rates and taxation, the people are keeping these places going, and the Minister has a responsibility to start telling them that the money must be spent the way he tries to ensure it will be spent in a local authority hospital, with accountability to the local authority, to the people who are paying the deficit grants, that is the general public. I know well it is a thorny and delicate problem and the Minister will require all his diplomacy to survive in his attempts to deal with this problem of telling these people they must allow him more access to these hospitals. He must see that certain practices are discontinued and that certain procedures are adopted by him which will ensure that the taxpayers' and the ratepayers' money is properly spent.

I was very anxious at one time to try to ensure that the combined purchasing section of the Department of Local Government was used as a condition of getting deficit grants. I thought that was a reasonable request. This section is very efficient, costs are pared to the bone and you make sure that money is spent intelligently. The Minister made a point regarding the question of ensuring that the hospitals are efficient from the administrative point of view. It seems to be an absolute precondition to the proper running of the service and the intelligent use of the limited money available for our health services.

I am in accord with the Minister on the broad principles he has outlined in relation to the reorganization of hospitals. There was a time in the 1920's and 1930's, with rudimentary ambulance services and bad communications, when there was a case for the Minister of the day to build county and district hospitals. Medicine was at a relatively primitive stage but that has now changed in a most revolutionary way. If a person is seriously ill and needs the services of an intensive-care unit, which is an extremely expensive apparatus, it is no use going to a kindly old practitioner in a general hospital. The Minister is correct when he says that this is not going to save a person's life. Wonderful things can now be done to save life at present in these intensive care units that have the necessary personnel. A doctor is now the centre of a large complex team; all the individuals in that team are, in their functions, inter-related to give a service that cannot be provided in a district or county hospital.

It is in the interests of the community that this fact be realised. I know the Minister will be under pressure from both my side of the House and his own party not to close down certain hospitals. I was subjected to this in a minor way and I do not envy him. He is going to have a difficult time because it is hard to persuade people about this fact but it is essential because medicine has changed so greatly. One might take the extreme example of a heart transplant team in which 40 or 50 people are involved. That is an extreme case but there are other services where it is easier to bring the peripatetic specialist to these regional institutions and have the patients come to him. I think the Minister will probably provide very good radio-controlled ambulance services, with resuscitation equipment and highly trained staff, and this will compensate for the lack of availability of a district hospital. The latter may be familiar to the patient but it is also a place where, because of lack of facilities, he could die. If the Minister keeps saying that to the public, eventually they will realise he is concerned and is not just closing county hospitals simply because he has nothing better to do. He is doing it for the positive purpose of improving the health of the community. I shall certainly support the Minister in his attempts to establish these regional hospitals.

The FitzGerald Report was a doctor's consultant report, basically hospital-orientated. It will repay the Minister to have a good look around himself, particularly at the United States, Czechoslovakia and a few other countries in which there are very advanced health services in order to make certain he is not simply building many enormous institutions which might suit doctors and surgeons but which now are not the best for the public. Apparently with the development of electronic equipment it is possible to establish poly-clinics for the examination of patients, with all the different forms of diagnostic facilities readily available. The patient need not be taken to hospital except for a short period for an operation, should it prove necessary.

According to some people with whom I have spoken, there is too high a bed occupancy ratio in our hospitals. There have been many cases where a person is taken to hospital for a relatively simple test on, say, Friday and kept until the following Friday when he could go to a poly-clinic and have most of the tests carried out there and a diagnosis made. In this way one would get the maximum use of these consultant-staffed poly-clinics. In this context the general practitioner will be the consultant—assuming we go along with the Todd Report and the GP becomes a consultant in his own status right. Just as any of us who wish to specialise in certain subjects must spend five or six years developing our specialty the same would apply to the general practitioner.

In these poly-clinics one "processes" the patient—it sounds rather inhuman but it is practical—and one finds out everything about him before he goes to the hospital. We tend to depend too much on the hospital and the Minister should make sure he is not being unconsciously misled by these people who are hospital specialists and very much hospital-oriented. From what I can gather this is not the development that is taking place in the more advanced parts of the United States and it would be worthwhile for the Minister to look into this matter before he makes up his mind.

I join with Deputy Ryan in deprecating the fact that a number of the voluntary hospitals simply do not want to care for the aged. That is very wrong. The new St. Vincent's Hospital at Elm Park has not got a geriatric section. It is absurd that a teaching hospital with the magnificent reputation it has should adopt this attitude towards the aged and geriatrics. As Deputy Ryan said, there is this shocking approach that if one is 60 or 70 years of age one has only got another 24 hours more or less to live. That, of course, is utterly divorced from fact. Geriatrics is a specialised study and it forms a very big part of the general practitioner's work and, because it does, it should be an integral part of any serious undergraduate training hospital.

I am sorry that the St. Vincent's Hospital on St. Stephen's Green will not become what I wanted it to become. I wanted it to be handed over to the Dublin Health Authority as a geriatric centre. I understood that the St. Vincent's authorities were to get Elm Park in exchange for the hospital on St. Stephen's Green and I insisted on adhering to that because I wanted it for the Dublin Health Authority for the aged. The hospital is ideally situated on St. Stephen's Green. I understand that not alone have the St. Vincent's authorities now got Elm Park but they have also got St. Stephen's Green. The Minister will correct me if I am wrong in that. I hope I am wrong. Any alteration in the original intention would be a retrograde step.

I see there is a 300-bed hospital to be cited in Tralee. I hope I shall not alienate my Kerry friends when I ask why there should be a 300-bed hospital in Tralee. Good luck to them, but I should have thought that the Limerick Regional Hospital, which is an excellent hospital, could have catered for that particular area. I should not have thought that the hinterland of Tralee would provide enough patients for a hospital of that size in Tralee. This is the first time I have heard this mentioned. I do not resent Tralee getting this hospital. The people of Kerry are more than welcome to it as far as I am concerned.

I trust the Minister will do something about the implications for us of the Todd Report. We turn out a surplus of doctors and there is a possibility that we might lose reciprocity with Britain. I do not think there is really much danger of that because I think they need us more than we need them but I wonder to what extent the Minister will assert himself, if I may use that phrase, in getting the teaching hospitals to do something about the entire training programme, both undergraduate and post-graduate, in an effort to rationalise it in some way. It is absolutely chaotic at the moment. I would not allow a son or daughter of mine to do medicine, as things are at the moment. The length of the course is appalling. All we have done is added on at one end and taken away nothing at the other end. The course is getting longer and longer.

I have the greatest sympathy with the average medical student and I wonder why anyone today goes in for medicine. A student finishes at the end of seven years in the university. He then does an obligatory year in a hospital. Then he starts his specialist training which may take another five years. I do not believe it is necessary for medical training to be that long. There must be some way in which one could devise streaming at a very much earlier level in one's medical training. Most of us are fairly sure what we do not want to do in medicine. I wonder could the Minister intervene helpfully to ensure that the medical schools revise the curriculum in such manner as to make it more appropriate to the needs of the student. The present course must constitute an appalling emotional drain on any person, most of the time pretty hard up and frightened of failing and being rejected because of failure. Somebody should do something about it. I know the Minister does not like intervening in these things but, if the Minister does not do it, nobody else will do it. I am dissatisfied with what we have done over the last half century from the point of view of health but it appears to me that the Department and the local authorities must take the initiative in medical education and I hope the Minister will feel he has a right to intervene.

I am astonished at the Minister's satisfaction with the school medical services. The total number of national schools is given as 4,800 in 1960-68 and 4,400 in 1968. The number of schools examined was 2,300 in the 1960-68 period and in 1968 the number examined was 100. The figure seems to be dropping. It is certainly not increasing. How could the Minister be satisfied with that service? Surely all the schools should have a medical examination. If they are not having a medical examination why are they not having it? Is there not a good case for suggesting that the school medical service is grossly inefficient and not functioning at all really?

Again, this was not the Minister's responsibility. I am just surprised that he is not surprised at the figures he has given me. He seems to be somewhat proud of them. I should like him to think over the whole business of the school medical service and his new health scheme. What precisely is he going to do? His statement is rather confused. It is difficult to know whether he is going to have the assistant medical officers of health who I am not certain are the best people. I say that without any disrespect to them. It is like asking me to do a school medical service. I would not know anything about it. It is just that the training of an assistant medical officer of health is not really in clinical medicine and it seems to me primarily clinical medicine and to that extent it would seem to me that the best persons to do these examinations are the local general practitioners.

That brings me to the whole future of the general practitioners and the general medical service, the fee for service payment, and so on, if I may just discuss it briefly. There will be some difficulty it seems to me if the Minister uses the county medical officer for health and his assistant to do these school examinations. What is the relationship between the general practitioner and the child in his new scheme? Presumably the child will be under the care of the general practitioner. The medical officer for health or his assistant comes along and examines the child. What right has he to interfere in the professional relationship between the child and his professional adviser, the general practitioner? What are we going to do about it? These people will overlap, surely, in the service to be provided.

On the question of the fee for service, I suspect that if the general practitioners were offered a fee for service then you probably would get a really efficient school medical service but in regard to the question of the fee for service in relation to the general medical service which is proposed by the Minister I personally, were I Minister for Health, would be very frightened indeed of a proposal to pay a fee for service. However, that is the Minister's worry. It is a highly dangerous proposition because of the possibility of abuse. However, I am glad of it for what you might call pragmatic reasons, I suppose, in so far as it will be a great improvement on the block grant for the dispensary doctor at the moment. There are grand dispensary doctors who give a first class service and so on but generally speaking it does not provide the service we require.

If there is a fee for service operated, I suppose, on a kind of panel system, where the person can leave the doctor if he does not get the service he wants or thinks he deserves, it is likely that the Minister's health scheme could provide a useful health service for the ordinary people. That is the reason I accept the idea of the fee for service proposals put forward by the Minister because the man-in-the-street is more likely to get an intensive health service if the doctor will get a fee for each service he provides for the individual. I do not know whether or not the Minister would be able to give us any further details in regard to this proposal concerning the general medical service. I suppose the truth is that it has not got to the stage of finality yet and he may not be able to tell us much about it. I do not envy him and, further, I do not envy the Minister for Finance when he comes to foot the bill because it will be a very considerable one indeed. That is his worry. As long as the public get a fairly good service I will settle for that.

In relation to the care of the aged about which we have been talking for a long time, there is one thing that I cannot understand. I cannot understand why this booklet has this imprint "1968" on it. Did it take two years to print? It goes back as far as 1966. I cannot discover when this committee was established. It is an interdepartmental committee—Social Welfare, Local Government, Health and so on. The committee made a very good examination of the existing services and made certain recommendations. The bibliography is excellent because it covers most of the people who have done any work on this thing at all. I only hope that it is not just pious hopes on the part of the Minister. I hope that many of the recommendations will be implemented.

As I have said to the Minister before on another occasion, it is in his own interests and again in the interests of the Minister for Finance to do something about the provision of these community services, to help relatives who want to try to keep their old people in the community. As he knows and as we know in St. Brendan's, there has been a tendency simply to dump the old people in, to get them certified and to put them into a mental hospital if they become just a little absentminded or wandering in their habits or cantankerous, or whatever it may be. The figures of the number of old people who find their way into our mental hospitals are appalling. It is a dreadful way to dispose of them —that is the only word you can use— discard them. It is a very costly way of dealing with them also. I am glad the Minister says he is to try to provide for community care of the aged. There is some care provided by voluntary organisations but it is only minimal. It is nothing like what is required. I am sorry to see the Minister says that the time required for bringing into full effect over the country as a whole such a concept of institutional services for the aged must necessarily be fairly long. That sounds very ominous to me. Remember, we have just about 50 years waiting for this analysis of the way our old people are treated in our community and that they are living at home on starvation allowances. There is no doubt about that.

I do not think that something must necessarily be wrong before the position is resolved, because many of these old people have not long to live. By the time the Minister gets around to providing them with services, they will not be there and for that reason the provision of care for the aged is probably the most urgent need of all. The Minister for Health, the same as the Minister for Local Government on housing, takes refuge in a formula, but the formula is always the same. It does not matter whether private houses are needed, swimming pools, schools or care for the aged, however, desirable it might be for a situation of unlimited resources to aim for that idea, we are told the money is not there and that is my case against the whole concept of society in which private enterprise, capitalism, believes. I agree that the money is not there, but the money is not there because it is not meant to be there. Capitalism is not interested in the mass of old people; it is only interested in its own old people.

Is Russia interested in them?

The Deputy ought to read Michael McInerney's articles in the Irish Times about his visit to Russia. The most moving part of his article concerned the manner in which the old people, particularly retired old people, are cared for. Instead of being thrown out of employment and forgotten, they have clubs to which they are all brought and through them they continue to be part of the society in which they earned their living. I have never been to Russia but I found those articles particularly moving. I was very impressed to read how these people, who do not profess our Christian beliefs, treat their old people.

In the Scandinavian countries, where people do not make much ado about their Christianity, I have seen superb conditions for old people, conditions comparable to those provided in the best hotel in Dublin, the Gresham, or some such place. That is why I am not in any way doctrinaire about these things. Like the Minister and Deputy Dockrell, I simply face the fact that there are not the schools, there are not the houses, we have not the money for old people, we do not employ all our employable people, we have high emigration and so on, and I say that a society which has so many defects is a sick society, a grossly defective society and a society which should be ashamed of itself. I do not think the Government can get out of their moral responsibility merely by quoting this formula at me every time I say we should care for our aged or our illiterates. If the Government were serious about wanting to do something they would face the situation as I face it. I do not like change no more than anybody else. I do not like taxation no more than anybody else; I do not like paying rates no more than anyone else, but as a human being one has a responsibility to these various sectors of society. I hate to see a child selling newspapers because I feel he should be at a secondary school or a university and I hate to see old people trying to carry sacks of turf home. I think the way we behave in this regard is disgraceful.

Successive Governments have tried very hard to make this system provide wealth in order to finance these various services but they have all failed and they believe in the system, but I have never made any pretence about believing in it, yet the socialist countries, those which have been operating long enough, have gone a long way towards solving these problems. It is not good enough for us simply to say that the money is not there. Every Minister has said that to me at some time or other. It is the job of private enterprise to make money for a minority. It does that extremely well. They live well. They get educated well. They get sick in comfort. They grow old in comfort and they die reasonably contented but they do this at the expense of the rest of the community. I do not want to develop that point, it is so self-evident that it does not need to be developed.

The Minister referred to the director of forensic psychiatry, but I should like to know what is happening about that appointment. I have dealt with this matter before, so I shall not deal with it at length, but these delinquents are very sad and unhappy youngsters and nobody seems to want to have anything to do with them. There is no psychiatric services to deal with them at the moment. People put up with them as long as they can, but they usually end up in St. Patrick's or Dundrum. Nothing can be done about some of them. They have to be locked up for life but others can be given remedial treatment, and this is not being done. The Minister would be very lucky if he could appoint this man as director of forensic psychiatry because the problem is going to persist and he is a man with outstanding authority on the problem. I would ask the Minister to intervene and deal with whatever difficulties are outstanding with regard to this appointment. If it is just a question of money the appointment would be cheap at the price.

There must be some arrangement which the Minister can make in order to deal with this problem. None of the psychiatric hospitals wants these people because they are very disruptive in their influence and are very difficult to handle. Everybody tries to avoid having them; the girls usually end up as prostitutes and the boys usually end up in Mountjoy. This is a very sad and shocking problem for society and urgent steps need to be taken to rectify the situation.

I am surprised that the Minister has not accepted the commission's recommendation about a national advisory council. He may be right. He has his recommendations which are fairly clear cut and all he has to do, theoretically, I suppose, is to implement them. When I was not sure of something myself I usually got a number of people who I felt were expert and set them up as a committee and told them to get on with the job and this practice was reasonably successful. He has made the case that it is in transition and when it is all over he will call them together but I think there is a good case for calling them together now because these experts advised him about mental illness, but if the Minister has made up his mind then nothing further can be done about it. I think such a council would be a safeguard to him because he has so many problems to deal with that it would be very difficult for him to keep an eye on everything and it will be equally difficult for his Department to keep its eye on everything but if he had an advisory council, representative of the whole country, he would be in touch with what is going on throughout the country.

I have spoken briefly on the drug problem. I am sorry to have to say that the Minister's effort in setting up a joint alcohol-drug addiction unit at St. Dymphna's Hospital is not working out. I suppose we should have anticipated that, of the people being treated there, one is the type who just wishes to sit around and read while the other type is the youngster who wants to play his transistor. Therefore, it will be necessary for the Minister to consider the establishment of another drug unit and leave St. Dymphna's for the treatment of alcoholics.

On the question of punitive offences with regard to certain drugs I should like to say that to me a person who is a drug addict is just like one who is sick with pneumonia. I do not believe in labelling a person as a criminal. That is why I should like to see us having a director of forensic psychiatry to help us reconsider our whole approach to criminality, criminology and penality so that this punitive element which is so endemic in our society might be removed. All these people are emotionally disturbed and punishment should not enter into the question at all.

The drug addict is a person who must take drugs just as somebody else must have a drink on his way home or just as the Minister smokes his pipe. These are all ways in which we deal with our anxieties. The drug addict is a very pathetic person. He is not a happy person and one could have nothing but sympathy for him. His problem is a difficut one with which to deal and, in some cases, practically insoluble. It is one of these problems with which nobody particularly wishes to deal because most of us feel so helpless when we lose our sense of omnipotence which we, as doctors, experience when we are able to cure people whereas with a drug addict very few people seem to be able to make any headway. I would simply make a plea, therefore, for a more compassionate understanding of the unhappiness of the unfortunate drug addict. There was a time of bedlam when we flogged our mental cases and when we used to put suicides on trial and sent them to jail. There was a time when the alcoholic was treated with contempt but, thank God, we now know they are sick people and we must accept the same attitude in relation to the drug addict. There is no question of punishing them.

There is just one type of person with regard to whom I almost join the punitive brigade and that is the drug pusher. In Russia, drug pushers are shot and while I do not condone capital punishment I have a certain amount of sympathy with the line they take.

That is one of the good things that might come out of Russia.

Drug pushers are sick people.

They are not sick but they are making plenty of money.

I would put a pusher away almost for life because of the terrible thing that he does. Perhaps one should be less emotional about these matters. However, I suppose the youngsters will find the drugs somewhere and while people like publicans, cigarette manufacturers or brothel keepers are all supplying a human need of one kind or another for distressed individuals the same might be said of the drug pusher. Perhaps the pusher could be treated just as the addict can be treated. I would be inclined to share Dr. Risteárd Mulcahy's point of view when he says that hashish is not a very serious form of addiction but I do not know enough about the drug to say so with any sense of authority.

As a result of questions I have asked the Minister I have received helpful information from him and I would like to refer to a few points arising out of that information. The Minister, apparently, has applied himself to the psychiatric services—services which so badly need somebody like him. He is lucky in so far as this is not, relatively speaking, a very costly problem but it is mainly a problem of personnel. For instance, one does not have to build enormous hospitals or specialist institutions for this service. Fortunately for the Minister he is taking over at a time when we are trying to get rid of the institution. We are trying to provide a community service made up of community nurses, public health services, psychiatric social workers, psychologists and psychiatrists as well as the various voluntary bodies, the mental health committee of one kind or another, day centres, hostels and so on. While I am aware that it is not a picnic from his point of view, he can do an enormous amount on a relatively small outlay. He simply has to provide the personnel but the personnel will have to be properly paid otherwise he will not get the quality that he should get. There is tremendous competition. There is a shortage of all these personnel in the United States and Canada, where all of us have reciprocity and where we can go without difficulty and get £7,000, £9,000 or £10,000 a year.

That is one of the Minister's difficulties. If I may explain it to him, he is very fortunate because in the old days the psychiatric service was predominantly custodian and, although there were many very fine people in it, there also were many who went into it because it was a simple job to do and they had a very pleasant existence in those institutions, becoming institutionalised themselves; that has changed, however, and where the Minister is fortunate is that now he is getting in that service fine young people who had gone away, who have been trained, who have a great sense of idealism and who have given up very fine jobs to staff the local authority service for the Minister.

I am asking the Minister to try to understand that that change is taking place. There are very fine quality people now in his institutions, his mental hospitals, who had gone away and who have come back from various places. They are extremely well qualified people who have returned simply because they are Irish and they want to come back to work for their own people. They are putting at the Minister's disposal the expertise they have gathered at great cost in other countries where they would not have the slightest difficulty in getting three times the money. I hope the Minister will appreciate that that is true of many of the people working in the service and that he will take every step in relation to finances to try to make life better for them so that they will not go away, as may happen in relation to some of them.

I believe in a salaried service for doctors and nothing else. That is my personal view and I think that, ultimately, will be the way it will be, though our pattern, our cultural outlook and so on, is quite different. The personnel in our psychiatric services are working in a society in which their psychiatric colleagues in private medicine, in the voluntary hospitals, are working at a much greater advantage though they are working side by side with them. In many cases the men and women in the public service are doing as good if not better work, but our institutions and the services in them are not comparable with the voluntary institutions.

I hope the Minister will do something about accepting the proposition —a development which I was always trying for as Minister for Health—of integration between the voluntary and the local authority hospitals. Each has something to give to the other. We have money and facilities of one kind or another and they have a kind of prestige which is of use to us. It is most desirable that John of God's and St. Patrick's, for instance, should participate in such a new relationship. It would be beneficial to both sides.

However, the important thing is that the Minister should face the facts that, one, his medical profession in this service are of consultative status and, two, that they are working in institutions which are inferior financially and in prestige to their colleagues in the voluntary services. I know the Minister is allowing private practice among the personnel in the public service. I did, away back and I did again at a point in time when I felt it was the only way I could get what I wanted.

On the other hand, it is obvious that the better the man the more time he will spend in his private practice and, of course, his private patients have a perfect right to his services: I suspect that the better the doctor the more he will find himself drawn on by private patients and that his public patients must then suffer. No matter how hard such a doctor tries, his public patients must suffer. On the other hand again, if you try the secessional system, you will allow those who want that kind of thing to come in and you will have a sort of cross-fertilization between the voluntary and the local authority services. They will be working side by side and both will gain. At the same time, the man who wants to make a lot of money will be able to do it. I know it has dangers, but I think it is something to which the Minister should give a lot of thought before he rejects it. He has first class people not only in Dublin but throughout the country. His job is to try to keep them and to try to attract more people back and to let them see it is worthwhile coming back. It is the personnel the Minister is depending on in creating these services.

This also relates to the introduction of a psychological service. There is a terrible shortage: there are only three fulltime psychologists in the 26 hospitals. That is not enough. It is grossly inadequate. They are people who are wanted all over the world—there is a tremendous demand for them everywhere. Therefore, the Minister will have to try to attract these people into his service. It will involve such matters as salaries and superannuation, something more than the circular issued by the Department recently suggesting that following investigation the Department found that in view of new commitments the provision of such people is beyond their ability and that nothing more than a spasmodic service could be provided in this field.

This is like trying to treat TB without X-ray equipment. One cannot begin psychiatric treatment without first being able to get a psychologist's report. There is great need to increase the number of psychologists in the psychiatric service and the first thing to realise is that the Minister will have to pay. It is as simple as that. In this connection, I remind the Minister that these proposals were made in a report as far as 1966. It is not enough, therefore, to issue a circular saying: "We cannot provide you with a psychologist service in the psychiatric service. We will not provide what we have said we would provide." I emphasise that there is extreme urgency to provide these services.

In relation to psychiatric nurses I am very pleased to hear that the Minister will deal with this absurd business of the psychiatric nurses having to account for stores and stocks. I wonder would the Minister care to ask for a document which a charge nurse in a psychiatric hospital has to fill in once a year. It is an outrageous document concerning spoons, forks, sheets, blankets, towels et cetera. This absurd procedure must be gone through once a year and, as some accountant once said, nothing is ever missing, which is, of course, absurd. They take things from here and put them somewhere else. Somebody gives 20 blankets to somebody else and his figures are all right. It is a waste of time and it is completely fallacious if it is believed that it is a strict and accurate account. This is without any disrespect to the psychiatric nurses. All this system does is to take up a tremendous amount of time, insisting that nurses spend their time in the ward. This is the greatest disability as far as we are concerned, because if they must sit in the ward and keep their eyes on spoons and cups they cannot be out in the community and out around the hospital. They cannot be away from these absurd things. That is not psychiatric nursing; it is housekeeping. I do not know what the Minister will do but I think he should take some steps to introduce perhaps some system of housekeepers who will take on the responsibility of dealing with this problem.

There is a document from the Department of Health dated 6th February, 1970, which refers to incremental credit for married nurses other than psychiatric nurses. Could the Minister tell me why psychiatric nurses have been excluded from this proposal to give incremental credit to married nurses? It has had the effect of causing married nurses in the Dublin Health Authority to leave the psychiatric service to go into some other part of the service where they can get the benefit of the incremental scales. To that extent we have tended to lose a certain number of our married nursing staff.

I am glad the Minister is to institute an educational scheme. It is very badly needed. It has been shown before that the public respond very rapidly and readily to educational programmes. I am sure the public will give the Minister every assistance in dealing with his various problems if he begins some sort of educational programme but, of course, he will have to be careful. There is a danger of carrying out an educational programme for a non-existent service. One gets demands on a service that simply cannot be met and then there is public disillusionment. I hope he will go cautiously about his educational programme particularly in regard to mental health.

In relation to the mental health committee I get the impression that it is not working particularly well. I may be wrong. There are many high sounding names on it but I do not think they are doing very much at the present time. However, the Minister may have another side of the picture.

I was very interested in Deputy Ryan's disclosure about the Mount Pleasant Hostel. He said the Dublin Health Authority had to buy it in spite of the Department. The Mount Pleasant Hostel is becoming one of the show-pieces of our health service here. It is providing a very fine service, a sort of day hostel type service. It is excellent. If the Dublin Health Authority were responsible for going ahead, with it, they have been well justified in their decision. I hope the Minister will personally look into the question of the provision of a hostel in the Clontarf area. I know there is a difficulty about money but the service that these institutions provide will save him again and again the money he is paying out for in-patient care. This is true of the geriatric case and it is true of the psychiatric case. If he could provide this kind of day hostel accommodation he would reduce considerably the amount of money he is spending on geriatric cases in St. Mary's, St. Kevin's or Crooksling or on psychiatric cases in St. Brendan's or St. Ita's.

In relation to St. Ita's, may I ask the Minister to look again into the question of Ward 8B about which Deputy T.F. O'Higgins also asked? The Minister told me that as far back as 1957 representations were made to have improvments carried out. It is now 1970. That committee of the Corporation, of ordinary Dublin laymen, used words like "intolerable", "scandalous", "outrageous" and so on about the conditions in that ward for mentally-handicapped youngsters. I suggest that for 15 years these conditions have existed. There must be some explanation as to why remedial action has not been taken for the sake of the unfortunate patients and of the staff. Would the Minister please look into this as a matter of urgency and see that some steps are taken to deal with it?

I find it rather depressing that the Minister's approach to the problem of the mentally handicapped young is that they will be cared for when they get the accommodation vacated by adult mental patients. That seems to me to be an inadequate solution because, first of all, it will take a long time to provide the space needed for the adult mental patients; and then the kind of accommodation being vacated is usually so bad that it is not fit for anyone. Therefore, it seems it will be a long time indeed before the unfortunate mentally handicapped youngster gets care. It is particularly distressing for the families of mentally handicapped children to have this dreadful dilemma of trying to care for the children knowing that, if they keep them at home, the time will come when they themselves will die and the children will end up in an institution. On the other hand, if they put them in an institution they will be parted from them. There should be domiciliary nurses visiting them, psychiatric care, general practitioner care, whatever they need, to keep the youngsters in the home if possible because a youngster will do better at home than if put into the appalling lost anonymity of, no matter how well run the institution may be, a hospital for mentally handicapped children.

Might I pay a tribute to the St. John of God people? I have done it before. i have tremendous admiration for them particularly in relation to the Obelisk Park place which they have for children of this kind—epileptic and retarded children, and so on. It is one of the few places where we can send anybody to visit and to show them simply superb conditions either in the dormitory accommodation or, as I feel is even more remarkable, in the small families—half a dozen houses in which these young people live in groups of seven or eight and where there is a houseman or a house father, and so on. That seems to me the way all our institutions for orphaned and illegitimate children, and so on, should be organised. I think the order of St. John of God is Italian in origin. All over the world, they are away ahead in this matter. They have given a great lead here in Ireland. I do not know if the Minister has ever visited the place. It would be well worth his while to go out to see the work being done there which, to a considerable extent, I am afraid, is not being done elsewhere.

One last point in relation to the FitzGerald Report which I should like to make concerns the making of appointments. It arises under the attempt to link the voluntary and local authority services. It is very important that the Local Appointments Commission system be retained in the making of appointments under the new Health Act—the regional authorities and that kind of thing.

Notice taken that 20 Members were not present; House counted, and 20 Members being present,

The Local Appointments Commission is an institution which has earned the respect of all sides of the House in spite of criticism of it from time to time. I think most of the criticism has really not been well-founded. Undoubtedly, it is terribly slow in its operations. The Minister mentioned a figure of 57 months, or something like that: there were many reasonable reasons why it should take 57 months to make an appointment. Obviously, it is much too long. However, it is far superior to the system of appointment in the voluntary hospitals where the people making the appointment may simply be lay people: they may be appointed because of their associations with or affiliations to one or other of the secret societies or the semi-secret societies in the community. There may be no advertisement of the posts. The qualifications for the posts may not be declared, and so on. There are many anomalous decisions and situations in the making of appointments to the private voluntary hospitals, which are avoided in the making of permanent appointments to the local authority service.

The Minister should fight very hard indeed to try to keep the local appointments system as the appointing system in the making of appointments under the new dispensation, under the new regional hospital boards, because there is no doubt that the Local Appointments Commission tried very hard, indeed, to get the best person appointed to the post. The reasons for their slowness are usually explicable. The appointing system is very inefficient in this way. It is impossible to decide, particularly for a very senior post, after ten or 15 minutes or half an hour or whatever it may be talking to somebody, that that person is the best person there. There are now very sophisticated and very advanced——

A Leas-Cheann Comhairle, I think it is fantastic that Deputy L'Estrange, the leprechaun L'Estrange, comes into this House on the Fine Gael benches, calls a House and then disappears. I think you, a Leas-Cheann Comhairle, should take notice of this effort on the part of the Fine Gael Party to disrupt the proceedings of this House. Deputy L'Estrange has gone back to sell more land to foreigners down in his local county.

In conclusion I hope the Minister will fight very hard. The Local Appointments Commission were introduced away back in the thirties I think. They have performed their function extremely well on the whole. They should adapt themselves to the new and more sophisticated facilities which are available for individual personality assessment and so on, so that they will be more likely to get the most suitable person for the post advertised. I shall be very interested, indeed, to watch the progress of the Minister over the months ahead in his attempts to implement the many very valuable recommendations he made in his introductory speech.

Deputy Dr. Gibbons.

Why does Deputy L'Estrange not offer, or has he gone?

Once again one must be impressed at the manner in which the Minister has presented his Estimate to the House. As usual his statement is exhaustive and gives a large amount of detail. This is what we would expect from him. Since he was appointed Minister for Health we have been impressed by the manner in which he has grasped the problems with which he is faced.

At all times health must concern every one of us, whether we are in good or bad health. It is becoming an expensive service. The Minister has shown this in the increased amount of money that is required now compared with ten or 12 years ago. He pointed out something that will be welcome to the people down the country and particularly to the ratepayers. Once more his Department are prepared to take up a large part of the increased cost of the health service to the local authorities. He pointed out that the substantial amount made available was sufficient to limit the health rate increase to 2/- in the £. For this he deserves the thanks of the people, particularly the ratepayers who complain about the ever-increasing burden of the rates.

He referred to the fact that the Health Act will be introduced on 1st April, 1971. He pointed out that the staffing aspect of the new authorities is an important one and that he is now in the process of setting up a joint consultative council to smooth out the transfer of the staff. This brings me to a point about the dispensary medical service. He promised that those of us who are now in the dispensary medical service will be retained there and that we will have an automatic right to enter the service and take part in the new scheme.

There are some dispensary medical officers at present who I am informed may not be prepared to take part in the scheme for one reason or another. As I understand it, under some section of the Local Government Act they can opt out if they feel the conditions would not be fair to them. Before he drafts the final regulation to deal with this transfer of the dispensary medical officers into the new scheme, the Minister should look into this and, if there are any medical officers who find that their conditions would be worsened by entering into the scheme, he should provide for them. Strictly speaking, this would be a matter for the Minister for Local Government but the initiative must come from the Minister for Health when he is drawing up the regulations for the new service and particularly its financial aspects.

At this stage no district officer is sorry that the dispensary medical service is being changed. Under the new scheme the patients will be getting something which we all have no doubt they are entitled to, that is, choice of doctor. Unfortunately, in some parts of the country this choice of doctor will be very limited. There are many dispensary posts in the west of Ireland, quite convenient to me, which have been vacant for some years because no doctor was available to fill them. It appears to me that this position will worsen in the future. As I see it, at the moment instead of patients having a choice of doctor fewer doctors will be available to them. In the next 12 months this is one aspect of medical service to which the Minister and his Department must give their attention.

It is difficult to know why this should be the case because, in the past, those areas have had their doctors. When one comes to consider it, it must be accepted that the primary reason is a financial one. Some extra inducement will have to be given to get doctors, and particularly the younger doctors, to come into those areas. In some cases houses will have to be provided for them or at least they should get a rent allowance to provide a house for themselves.

Another vitally important aspect of this appointments system is that they must be offered some outlet from those districts in the future. In the past the county manager had the right to transfer a medical officer from one dispensary to another.

Progress reported; Committee to sit again.
The Dáil adjourned at 10.30 p.m. until 10.30 a.m. on Thursday, 9th April, 1970.