First of all, I wish to thank Deputies for the very constructive way they dealt with the Estimate and for the very pleasant things they said about me, to some extent, and about the officers of my Department. I should like to take this opportunity of saying to Deputies who referred to the officers of my Department how splendid I think they are. They deal with innumerable deputations, some 30 separate boards, committees, commissions and other bodies of various descriptions and it has been a delight to me to move through functions of various kinds and to hear consultants, doctors, GPs tell me how lucky I am with the officials of the Department I have to work in. I wish to pay them that tribute.
They are far from being the traditional type of civil servant so well described by people as being the conservative kind, incapable of looking forward to future developments. I have had the most happy experience of civil servants in all Departments but in a Department with the complexity, the tremendous volume of work, of the Department of Health, a public tribute is due to those who conduct the service.
Deputy O. J. Flanagan spoke about my meetings with the county councils on the question of the establishment of the regional health boards and he said I had done so in a courteous manner. I thank Deputy Flanagan for his remarks, but obviously when one wants to make revolutionary changes in the health services one must do the best one can to satisfy those who have given loyal service to the health system with very much smaller units operating. It is essential, therefore, to meet them to get their understanding and sympathy. For that, one had to listen to discussion, prolonged in some cases. They met me on the whole in a very sympathetic way. They understood the problem and the necessity to provide better health services, more streamlined services.
I am dealing with some of the miscellaneous matters which have arisen first of all. There were some references to medical education. All I can say is that I consult with the Minister for Education who is mainly responsible for this matter through the support given to the universities. As well, officers of the two Departments consult to see what can be done to facilitate discussions of suggestions that have been made for changes in medical teaching and having an examination made on a purely voluntary basis. There is a committee set up in the Royal College of Physicians and the Royal College of Surgeons dealing with the implications of the growth of specialised teaching within the terms of the Todd Report.
I do not wish to comment now on the suggestion that medical courses are too long. We graduate 250 to 270 medical students in this country biannually of whom we need 100. It is a great vocation and it is true to say that in Great Britain and in other regions the medical services would collapse were it not for Irish doctors and nurses. It is a natural vocation for Irish people.
The courses are examined within the universities from time to time and I heard the other day that the course in relation to anatomy, where an awful lot of natural absorption is required, is being examined. That is all I can say about medical training. What we try to do is to get people to discuss it. We are in no way responsible for the rationalisation of the two universities: the Minister for Education is responsible and he consults us from time to time if any proposals come in which require to be fitted in with the hospital system.
Deputy Dr. Gibbons as well as some other Deputies made one or two remarks about district medical officers. We propose to apply the principle of arranging for doctors to take part in the choice of doctor scheme whereby they will spend periods in the more remote rural areas on the condition that they will have a post in an urban area which may be more suitable to their personal circumstances or to the education of their families.
The trend in regard to living in rural areas may change within the course of ten years. I notice that quite a number of people who come back to this country do so with the deliberate objective of living in a rural area rather than in a town. Rural life has its social advantages and disadvantages and, in the case of doctors, relates to the education of their families and to their particular enjoyment of the country. I agree with Deputy Dr. Gibbons that, perhaps, the arrangements we are making for district medical officers may help us to overcome the difficulties. There are places where it is very difficult to provide the kind of medical service that is based on people being permanently placed in a particular area.
Deputy Dr. Gibbons also referred to district medical officers who may wish to opt out of the choice of doctor scheme. The position is that permanent district medical officers will be assured at least of their present salary and will retain their pension rights. There will be special superannuation terms for any of these doctors who wish to opt out. Temporary district medical officers of two years standing have been assured of admission to the new scheme but, as the House knows very well, we are now negotiating with the Medical Association and the Medical Union on the question of the choice of doctor and on how the service will be remunerated and administered.
I shall deal next with questions which seem to have more relation to financing the various aspects of the health services than to the services themselves. Some Deputies suggested that we were not spending enough money on health services. International comparisons are difficult to make because health services are compounded of taxation, rates and insurance contributions in different proportions in different counties. However, if we take the first 18 countries in order of gross national product we find that the precentage we are spending is a respectable one. Some people may say we should be spending more but at least we are in the respectable arena as it were and from comparative studies that have been undertaken there is nothing to suggest that there is gross under-spending on our health services.
A Deputy suggested that because we do not have more satisfactory arrangements for subsidising the health services a number of people who should go to hospital are not doing so. I can hardly believe that is true. The number of persons entering hospital is increasing by three or four per cent per annum and in the current year the number of people who entered hospital was about 300,000. As a proportion of the population that is also a comparable figure with the well to do countries and I might add that the earnings of the people have more than doubled within the past ten years in real terms while the standard of living has gone up by about 40 per cent in that period. No doubt these factors are an encouragement to people to seek hospital services. Having regard to the numbers entering hospital each year, exclusive of certain classifications of people who must have immediate treatment, there is no evidence to indicate that large numbers of people are failing to go to hospital because of fear of the cost or because of the cost of drugs.
Deputy Ryan referred to the choice of doctor scheme negotiations. He is completely out of date with regard to negotiations for general practitioners under this scheme. A meeting with the medical associations is taking place today in the Custom House. We have put a particular scheme to the associations and this will be considered at today's meeting and subsequent meetings.
Deputy Ryan said that hospital doctors should be paid while they are sick. Any doctor who is prepared to join the local authority service and who can get into that service is paid during sick leave. There is no provision for payment to voluntary hospital doctors while they are ill. We have not yet been asked to take part in negotiations for such doctors but if and when a new method of payment is negotiated sick pay will undoubtedly fall to be considered.
Various Deputies referred to the cost of drugs for the middle income group and they mentioned that there is a scheme in existence under which, when the cost of drugs constitutes a hardship, the health authority can provide a contribution towards the cost of such drugs. I do not think we need say any more except to point out that during the course of the debate on the Health Act of 1970 I said that with the consent of the Minister for Finance we would be making arrangements whereby people in the middle income group would receive a subsidy towards drugs which cost more than a certain amount per month. A figure in excess of £2 per month was suggested but this suggestion is not necessarily the final one. As the House is aware, the subvention for drugs for long-term disabilities is also provided for under the Health Act.
I do not propose to debate the question of insurance for the middle income group because the matter has already been discussed but I should like to say that the Government have examined the possibility of introducing insurance contributions to offset the cost on rates for the health services. The possibility is being examined at considerable length but there are great difficulties involved. For example, the contributions in the case of self-employed persons would be very costly to administer. The whole question must be examined in relation to the general claim that agricultural incomes are lower than other incomes and there is the question of whether farmers should be asked to contribute to the health service in addition to the taxes that they already pay in various ways.
The question of where to draw the line is also a point of interest and I very much doubt whether people in the middle income group would consider that they were doing anything but paying taxes in a different form. I do not know what their reaction would be to the idea of having insurance introduced into the health service with the voluntary insurance scheme operating at one end and the medical card scheme at the other end. I do not know what the reaction would be of those people who would be asked to pay what would only be a partial contribution towards the cost of their health services. There is always what I might describe as the psychological receptivity to taxation about which all those who have served for many years in this House will know a great deal. It is possible to charge a person so much for a packet of cigarettes and he will pay the amount of the tax on the cigarettes.
If you suddenly, for example, put another 10s on his insurance stamp or made him pay 10s a week towards a middle-income group service, and if he knew that that, in itself, would not pay for the whole of the middle-income group service, his receptivity to such a proposition might not be, in effect: "Here is a wonderful contribution scheme. I am paying the contribution and I am getting the service." It is an extremely complex matter. We shall have to examine it again. At the moment, I have suspended action on it —at least until the Health Act, 1970, is implemented. But, having said that, regulations will be coming before the House for the medical card group standards and the middle-income group standards. This question can be debated there again. There can be an opportunity for an examination of the standards for the middle-income group which perhaps, without any great extra cost to the State, could be made more flexible and could be an answer to some of the objections by Deputies in regard to the manner in which the middle-income group decisions are now made. I am not making a false promise. I do not guarantee that there will be any marked level of change in relation to the middle-income group standards but there might be, within the framework of what we do, perhaps an examination of certain kinds of disabilities which might be looked at—such as people with large families on the fringe of the middle-income group at the lowest end of it.
I think the nursing profession is very wonderful. I shall always take a sympathetic attitude towards suggestions made, and proved, that the nursing profession is inadequately paid. I have paid public tribute to the nursing profession. I realise that, compared with the rest of the community, up to some years ago they were very badly remunerated. The situation has improved in the past five years. Within quite a short period of years, the situation of the general and psychiatric nurses has improved with increases of the order of from 47 per cent to 67 per cent. Their hours have been reduced to an 85-hour fortnight. Increments have been granted in various circumstances. We have at last arranged for married nurses who come back to the service to have an allowance of five increments for their previous service as nurses. The rest lies in the hands of the health authorities and the Irish Nurses' Organisation in regard to any demands that are made. Demands are, of course, constantly being made in all branches of the health service for increased remuneration. I just wanted to mention that there has been a considerable improvement.
Deputy Ryan referred to a recent march to Leinster House by a number of hospital nurses employed by the local health service. He alleged it was provoked by a long period of ministerial delay and inaction in regard to negotiation on nurses' claims. There is absolutely no basis for this allegation. Officers of my Department met a representative group of these nurses. The official cause of their protest march was dissatisfaction on the part of the nursing staff of the James Connolly Memorial Hospital with the existing system of appointment to ward sister posts in that hospital. They claimed that the nursing staff within the hospital had been deprived of sufficient opportunities for promotion. The inquiries by the Department into the complaints are nearly completed. We hope to convey the results to their organisation shortly.
The selection of nurses for promotion to ward sister posts is decided by the employing health authority and not by me. There is a very great demand for promotion to vacancies involving promotion to posts of ward sister and other grades to be thrown open to enable nurses who want to move from one place to another to have an opportunity of securing these appointments. Within a great many hospitals, there is equally a pressure for existing staff to have an opportunity for promotion. This is a matter for tactical understanding and for an overall point of view to be secured by the health authority in conjunction with negotiations with the appropriate organisation. I should not like to interfere with it in the ordinary way at all.
Deputy Ryan said that drug prices here are very much higher than in Britain. I do not think we have any great evidence of that. They may, in certain cases, be higher. I would not say it constitutes anything in the nature of a scandal or something that needs to be investigated.
Deputy Tully criticised me mildly for not bringing forward the new regulations for a standard system of means test for the medical card group at an earlier date. I simply had not the time. I am moving towards the implementation of the Health Bill in a practical sense by 1st April, 1971. The officers of my Department are stretched to the limit in regard to this whole change of administration. The regulations will come before the Dáil. I hope there will be the same constructive attitude in the debate on the standards devised for the medical card group and the middle income group. I do not believe that what I propose will please anyone. Naturally, if I were an ordinary Deputy, I never would be satisfied with what a Minister proposes for the first time, as distinct from a health authority. But, as Minister, I know that we have not an infinite amount of money and that it would not be possible to increase very greatly the total percentage of people receiving medical cards. I think the proposals will in the end be acceptable although perhaps everybody would like to see them more liberal.
Deputy Tully asked what would happen in connection with the health rate struck if there is an increase in salaries and wages this year. This will create a debit balance on the health account of the health authorities. I shall have to move a supplementary estimate for my contribution towards health expenditure. I cannot give any guarantee next year what I shall do about the health rate structure to the extent that it will have been increased by the cost of salaries, wages and materials arising from the 12th round of wage increases. It would be impossible for me to commit myself.
Deputy Tully also referred to the conditions under which student nurses operate. I hope that if there are nurses in a certain hospital which he mentioned who are not receiving the right kind of treatment they will take up their case with the Irish Nursing Organisation, which is fully competent to deal with it. Deputy Tully also complained in regard to a number of different matters relating to conditions of service and wages. I think he should know that there is proper conciliation and arbitration machinery devised for that purpose. I think he should know also that the Minister for Local Government is preparing a new and extended form of arbitration and conciliation machinery in the form of a board. He also knows what the attitude of my Department is. This is in the first instance the responsibility of the health authority but, on occasions we regard as suitable, we inform a health authority that we will facilitate them if they will consider certain matters in relation to pay and conditions which we regard as important to the health service. If we think there is an urgent need for some particular improvement, we let the health authorities know that we will gladly sanction certain changes that may be agreed to by them. On the other hand, we like the health authorities to take the first and major responsibility for changes in remuneration.
I come next to questions relating to the FitzGerald Report. Quite a number of Deputies spoke about closing hospitals. There is no proposal in the FitzGerald Report to close local hospitals, certainly not on any large scale. If surgery is not carried out in a county hospital the surgeons' wards will not be closed down but will be used for other purposes and will continue to be staffed. District hospitals will be retained as homes for old people. It is a question of the user of the particular hospital that is involved and, with the increased number of people who have survived to the ages of 70 and 80 years, we will need all the beds in reasonably well-built district and county hospitals for geriatric purposes. If the population in the rural areas increases we will also need more maternity beds.
I have already told Deputy Sir Anthony Esmonde that the Irish Medical Association, the Medical Union and the National Health Council have approved in principle the implications of the FitzGerald Report. That does not commit them to approving the detailed recommendations but they have approved the general principles involved in implementing the report.
I do not know whether I need argue again the case of the FitzGerald Report in detail. Deputy Hugh Gibbons was trying to distinguish between various kinds of surgery. I suppose it is true that there is what could be described as "cold" surgery—the simplest type of surgery, involving hernia, appendicitis and so forth—but I cannot find any well-versed consultant who could tell me other than that the chances of being restored to full health are better in a hospital with a number of consultants and more elaborate paramedical equipment. I cannot find any consultant to deny that statement and that is what is involved in the FitzGerald Report.
Deputy Hugh Gibbons referred to the necessity for examining this problem and this I shall do. There is no need for any county council or urban district council to start passing resolutions immediately, or to continue to pass resolutions, on this matter because I have promised to consult the local committees established under the Health Act, 1970, before there will be a change in the functioning of a hospital and local inquiry will also be necessary. One-sixth of the surgical cases in this country involve going outside the health authority area already and it rises to 25 per cent in the case of some counties. There is already a movement outside an immediate health authority area for people who require many kinds of treatment.
Observations were made on the time taken in relation to the surgery performed on a patient. We must compare the time taken to treat a patient in a regional hospital on a 24-hour basis with the time taken in the case of a patient who goes to a smaller hospital, has to wait for diagnosis and, if it is not urgent, has to wait for the surgeon. We must also consider the duration of convalescence. All these matters are the subject of examination by the experts when they make recommendations for larger hospitals.
Deputy Hugh Gibbons spoke about a rather controversial matter and I was interested to hear what he said. He spoke about the distance of a hospital in the instance of a patient suffering from an acute perforation of the appendix. There will be some doctors who will take the point of view that it is better for the patient to go to a hospital very quickly. There will be others who will say that the patient who is properly prepared for an emergency operation—whose appendix may have been perforated—who is conveyed by a good ambulance service to a large general hospital with all modern facilities will have a greater chance of survival than he would in a small hospital ten miles away. Some expert consultants would disagree with Deputy Hugh Gibbons on this matter. They would say that if a doctor puts a patient, properly prepared, into the ambulance it is probably better to send him in a grave condition to a hospital further away which has better facilities.
Deputy Gibbons made reference to the cost of patients in various hospitals and I think the best answer is this: I agree there is a certain amount of difficulty in analysing the comparative cost of patients in one kind of hospital and another. There is a variation in the age levels of patients in different hospitals and a variation in the extent to which elderly patients are taking treatment and will spend longer in a hospital than young and vigorous patients. The Medico-Social Research Board research into bed occupancy may yield interesting information on all matters about which Deputy Gibbons spoke so sympathetically, namely, that if we are looking into the implications of the FitzGerald Report we must examine the comparative costings apart from the main point which is to ensure a better service for the public and reduce mortality.
Any proposals made to have a second surgeon in a hospital or to have a visiting surgeon come to a hospital must be examined not only in relation to what the people would like to have. There must be a sufficient work-load to enable the surgeon to consider that the job is worth doing. You could construct an ideal system for consultants and surgeons all over the country designed to give the best treatment, and you would not get people to apply for the positions because if they were not spaced according to requirement there would not be a sufficient work-load. The work would not be interesting and would not result in their being able to get promotion because they would not get the experience necessary.
One Deputy suggested that a surgeon should be available on the premises of maternity hospitals. There is an enormous number of normal maternity cases examined in hospitals where there is not a surgeon, but the real answer is that we ought to have the maximum consultation for maternity cases by an expert consultant obstetrician who will decide whether it is safe for the mother to have her child in a hospital with no special facilities for emergency treatment, or whether the mother should go to a hospital having full gynaecological services. That is the test that should be applied.
Deputy Gibbons spoke most constructively on this matter. He recognised my difficulties but at the same time he spoke out, as did other Deputies, for the perpetuation of single-surgeon hospitals if at all possible. I was glad he recognised the difficulties involved in the Todd Report. The implications of that report will not have very great effects for three or four years.
I should say, in passing, that I do not want to give any indication that what I am saying refers to any particular individual but, in regard to certain appointments made in the last five years—I say five years so that no one will gather what the particular place is—one can see the beginning of the difficulty of finding at a particular time, when one is looking for a particular person, a really competent surgeon where there would be competition by others for a single surgeon hospital. We are beginning to see that process taking place and I am being sufficiently vague about it because I do not want to suggest any particular individual is involved. I make the statement advisedly that the signs are already there.
I now come to the question of psychiatric illness. Deputy Dr. Browne made many constructive observations in regard to psychiatric medicine. An appointment to the post of clinical director for forensic psychiatry under the Dublin Health Authority is now in train following a recent competition. I am sure the Deputy will be glad to hear that.
The Deputy also referred to bed occupancy reduction in relation to attendances at psychiatric clinics. I would remind the Deputy that the cases treated in these clinics are not necessarily cases which would have occupied beds if they were not attending clinics—those suffering from neuroses, inadequate personalities, behavioural problems, etc. For others attendance at clinics may postpone hospital admission. The Deputy will agree with me, I think, that more can be done to keep people in the community than is being done at present and I am having a meeting with county managers and resident medical superintendents within the next few months to discuss the implications of the report of the Commission on Mental Illness. We are making advances but the resident medical superintendents and their assistants will have to move together in step with us if we are to make the progress we want along lines upon which I might say I see very little disagreement between Deputy Dr. Browne, who is an expert in this field, and myself and the officials of my Department. We are all agreed on keeping people out of mental hospitals, on having more domiciliary attention, more short-stay accommodation and more outpatient clinics, with nurses visiting the patients in their homes. We are pressing forward to that end as rapidly as we can.
Deputy Dr. Browne asked about the reduction in the number of patients in St. Brendan's. The reductions represent a real reduction in the numbers resident. They are not due to reclassification in any part of the hospital itself.
There have been comments on overcrowding in Portrane. We do not want to increase the size of mental hospitals and the Dublin Health Authority is being asked to consider the provision of accommodation elsewhere for some of the geriatric patients in Portrane. We are awaiting a reply from the health authority.
Deputy Dr. Gibbons referred to the fact that it was no use sending people home from a mental hospital unless there are follow-up visits. This is the basis of the policy. The policy is to have some of the psychiatric workers in the mental hospitals visit patients in their own homes to make sure they are taking any drugs prescribed, to discuss their condition with their relatives and to find out if their condition is deteriorating or improving. If it is deteriorating they will be referred back to the psychiatric specialist. We shall have to make very considerable progress before we perfect the system. It is as yet only in the initial stages.
Deputy Ryan asked about autistic units. The unit in Cork is not yet available but the unit at Beaumont is operating and is taking patients from all over the country.
I think it was Deputy Ryan who referred to the undesirability of having drug addicts and alcoholics in the same unit. The Dublin Health Authority have now decided to find other premises for drug addicts. Drug addicts and alcoholics will no longer be housed in the same unit.
Deputy Dr. Browne referred to the thousand bed differential in regard to the salaries of medical superintendents of mental hospitals. We are satisfied this type of differential is undesirable and we are looking into the matter. The Deputy knows we have been examining the grading of the staff structure of mental hospitals. I answered a question tabled by him on this subject recently.
There is an exclusion of psychiatric nurses from the grant of increments to married nurses because we have not had any demand for this concession and no difficulties are experienced in regard to the number of psychiatric nurses available.
With regard to child health services, there seems to be some misunderstanding about the operation of the service. The children are examined by the county medical officers or the assistant county medical officers They are referred by these to the general practitioner in charge of the child or associated with the family. The ACMO may tell the practitioner that the child needs to be hospitalised and ask if the practitioner would object if he sends the child or would the practitioner prefer to make arrangements himself. It is a matter for the general practitioner then to say which course he prefers. There is no question of by-passing the general practitioner.
I do not accept Deputy Ryan's contention that gastro-enteritis is due solely to bad housing. It arises from various causes. It is not a precisely defined disease and a great many people who are said to be suffering from gastro-enteritis are really suffering from a virus infection. There are recognised preventive measures, but the disease is still too extensive in this country. There is need for the education of mothers or mothers-to-be in infant feeding, in the value of breast feeding, in the need for hygienic methods of preparation of feeds. I shall soon get a report prepared by a committee of the Medical Research Council on gastro-enteritis in Dublin. I have seen the results of some research done in Cork and it is quite clear from that research that some mothers were not sterilising the bottles properly. The public nurses will encourage mothers to sterilise bottles and that will be very valuable, particularly where housing conditions are poor. I recognise that better housing conditions are essential if morbidity is to be reduced but the incidence of the disease is not due solely to bad housing.
There seems also to be some implication that I have expressed myself as being entirely satisfied with the present school health service. On the contrary, I have decided to implement a four-year programme for its improvement by reducing the excessive number of routine medical examinations, by bringing the parents in greater numbers to the smaller number of examinations, by arranging to have teachers note certain very obvious defects to be examined in children and by having a truly selective examination when the child first goes to school. I am not prepared to say that the present child health service is anything but extremely effective even although it can be improved. The child health report that was furnished to me showed that the school health service found 223 health defects requiring specialist attention for each 1,000 children examined. By contrast, only 27 defects per 1,000 children were being treated outside the school health service and the proportion of children examined, while not perhaps as much as one could wish under the prevailing system when there were a great number of examinations, nevertheless, I think, was splendid. There were 135,000 children examined in one year. I do not think we need be ashamed of that but as I have said the system will change. It will take four years to make this change.
Deputy Oliver Flanagan referred to health education. It would take me too long to speak about that in detail. We are extending education this year both on radio and television and through leaflets. A great deal is being done in relation to smoking, to dental care and so forth. We do issue leaflets for mothers-to-be on preparing for their baby and on the diet they should have, and so forth. There is a series of leaflets produced and Deputy Flanagan need have no doubt that mothers are given the chance to find out what kind of diet they should have when they are expecting a baby.
There were a number of matters relating to hospitals in general. Deputy Dr. Browne queried the need for a new 300-bed hospital in Tralee and suggested that the area could be catered for by Limerick regional hospital. The proposed hospital in Tralee will replace the existing county hospital which is not up to standard and the medical, surgical and maternity services required for County Kerry, which has a scattered population of about 113,000, involve the construction of this hospital and it is not outside the ambit of the kind of considerations that were mentioned in the FitzGerald Report and which long before that were taken into account in deciding where a new hospital should be.
Some Deputies referred to the whole position of voluntary hospitals. I hope to secure the co-operation of voluntary hospitals to engage in further integration with local authority hospitals, to engage in management and work study and I hope that they will also consider any request made of them, if it was felt by a regional health board or by a regional hospital board that a particular voluntary hospital might participate in looking after geriatric cases. All that will be part of the work of the new regional health boards and new regional hospital boards.
There is a greater proportion of people staying in St. Kevin's Hospital for a longer period because on the whole the ages of patients in St. Kevin's tend to be older and the younger and stronger patients in Dublin are treated in the acute voluntary hospitals. That is the answer to that query.
A number of Deputies referred to out-patient facilities and to the long delays experienced by patients waiting to be examined. We are going into this. I quite agree with everything the Deputies said. There will have to be an examination of this matter.
The annual output of radiographers is 12. I am not aware of any serious scarcity of such staff at present. The existing training school will increase its annual output by 50 per cent, from 12 to 18, when its activities are transferred from St. Vincent's Hospital, St. Stephen's Green, to the new St. Vincent's Hospital at Elm Park. That is the answer to the Deputy who suggested that there was a great scarcity of radiographers.
Some Deputies referred to a shortage of nurses. An Bord Altranais are going to conduct a survey, which should highlight the reasons for shortages, in the form of a questionnaire addressed to nurses which should give us some useful information about the whole nursing position.
Deputy Tully referred to meals in hospitals. I would encourage hospitals to give a cup of tea and some biscuits to patients who have to be kept waiting a long time and who have come from long distances. I understand it is quite possible for them to do this under the existing Health Acts.
I understand in regard to Deputy Dr. Browne's question about the financial advantages for voluntary hospitals participating in the combined purchasing scheme with the Department of Local Government for their materials that voluntary hospitals have been encouraged to make use of the facilities offered under combined purchasing arrangements and they use the combined purchasing scheme, particularly in relation to furniture, equipment and medical supplies. Perhaps they should use it more. Nevertheless, I do understand that they are making use of this very excellent system.
Deputy Dr. Browne asked a question about the daily occupancy figures for non-surgical, cardiological, non-TB patients in Merlyn Hospital, St. Stephen's Hospital, Sarsfield Court and James Connolly Memorial Hospital. These figures were included in the statistical data circulated to all Deputies, except in the case of the James Connolly Memorial Hospital where all non-TB acute patients are admitted with a view to surgery.
The Deputy asked what was the future use of the three sanatoria. In the case of the James Connolly Memorial Hospital it is proposed in the immediate future to use part of the hospital as a general hospital which will initially have 120 beds and to use the balance of the accommodation for tuberculosis and geriatric patients. It is intended at a later stage that a general hospital will be built on this site. The services provided at Merlyn Park Hospital will be integrated with those of the regional general hospital in Galway to form a major hospital complex providing specialist services for the western region and general medical and surgical services for the appropriate catchment area. St. Stephen's Hospital, Sarsfield Court, will be used mainly for the treatment of psychiatric patients.
I should have said in reply to Deputy Ryan and others with regard to the out-patient difficulty that a study has been carried out in association with the Irish Medical Association of the out-patient problem and the results are being processed. I hope it will be possible to effect improvements but this is going to be a very difficult matter. There is, first of all, the punctuality of the patients themselves and there is the difficulty of predicting how long it will take to treat a patient having a particular condition, by a particular doctor. It is not an easy form of work study, as one might describe it, or time and movement study, to process effectively but I hope we will be able to make progress because, there is no question, there are appalling delays.
Deputy Ryan and others asked a number of questions about additives in food. The Minister for Health has power to control additives in food through the operation of Part V of the Health Act, 1947. Additives are controlled under section 56 of that Act which relates to the fixing of standards for the composition of food. Following the advice of the food advisory committee comprehensive regulations dealing with the control of additives such as lead, anti-oxidants etc. will shortly be made by me. They have already been approved by me in principle and will come into force with provision for a transition period. I think this will bring us up to date in regard to the whole question of additives.
I hope Deputy Tully will give me some more information about the syringes left on a beach in Meath by a group of people who came there and made trouble. That kind of information should always be made immediately available to the Garda Síochána.
I do not think there is any need for me to deal again with the question of drug abuse, I have already given the House a full account of it. However, regulations will be put into operation within the next two or three weeks arising out of the section in the Health Act which will enable the Minister for Health to control the use of another group of drugs other than those already controlled under existing legislation. The Garda Síochána drug squad is either increased or is going to be increased. We have the Jervis Street and St. Dymphna's unit for both day and residential treatment of patients. I hope the operation of the Health Act dealing with drug abuse will be effective. There are very few countries which have prohibited the sale of amphetamines and we are still in the company of the very few countries who have done this. The whole problem will continue to have our attention. I want to make it clear that no Minister for Health anywhere in the world has prevented addiction to dangerous drugs. All Ministers for Health can do is to make it as difficult as possible for people to get hold of these drugs. I am no different from any other Minister in regard to this fearful problem.
Deputy Ryan was wrong in saying that the misuse of electricity was a major cause of death in connection with home accidents. There have been 13 deaths from misuse of electricity and defective electrical connections in the period from 1958 to 1968. The major causes of death are open fires, scalds, burns, falling asleep while smoking a cigarette, the physical conditions of floors and so forth. All these matters are dealt with in the report on the care of the aged.
Deputy Ryan said that the State should help to subsidise the payment of home assistance. I have made it quite clear in connection with the Health Act that I hope home assistance officers will be employed by health boards so that they can co-ordinate with all the other staffs in relation to domiciliary care and domiciliary examination of people, but I cannot arrange for any subsidy to be given in respect of the cost of home assistance by itself and this will continue to be levied from the rates.
Deputy Flanagan made a mistake when reading the Estimate. He thought that in relation to homes for the aged £190,000 was the total provision but the subhead which he referred to, namely subhead I, merely provides for the Exchequer contribution of 50 per cent towards the loan charges on borrowings by local authorities for this purpose. The statistics we circulated showed the extent of the work completed last year, or in progress or at an advanced stage of planning. Deputies can read these reports in the memoranda which I circulated before the debate began. Works completed last year will accommodate 1,200 old people and works in progress will accommodate nearly 600 old people, so we are making progress here. We are going to go ahead with our programme for the care of the aged and this involves participation by community associations in all these arrangements. I should like to commend all the community associations now operating and it is through community associations that we want health authorities to give assistance such as is provided for in the present system and which will become more available when the Health Act is fully implemented.
Deputy Ryan suggested that my Department prevented the Mass Radiography Board from screening the population for diseases other than tuberculosis. This, in fact, is not so. It is the board's practice that when X-rays uncover a non-tuberculosis chest condition of significance they do bring the matter to the patient's attention so that the patient may have the condition investigated fully.
Deputy Dr. Browne spoke at length about lung cancer and its connection with cigarette smoking. It is now generally accepted that cigarette smoking makes a contribution towards coronary heart disease. I am going to consider what more can be done to educate young people about the dangers of smoking but I will not forbid smoking in this community. Constant increases in the price of cigarettes have not stopped people from smoking. People are still smoking who have read all the publicity about it, who know all about it and who either believe or do not believe what they have read about it. If I were to forbid cigarette smoking many people would turn to some other form of addiction. They would go in for placebos or some other drug to relieve their anxiety and to make them feel more cheerful. I disagree that death by lung cancer is nearly as serious as the ultimate effects on a family of addiction to dangerous drugs. Neither do I think the effects are so serious as those of alcoholism which, as I indicated in my opening speech, result not only in the alcoholic going into a home but also result in members of the family going into a hospital or home as a result of that alcoholism. What I intend to do is to see what more can be done in relation to health education in this matter. As I have already indicated, cigarette advertising on Telefís Éireann will cease at the end of this year.
I do not think I need give the House any great details about what we are doing in relation to propaganda against cigarette smoking but the House might like to know that the National Film Institute includes in every school health film show of which there are 1,000 a year, on our behalf, the film Smoking and You which graphically illustrates the dangers of cigarette smoking. We also participate in a mid-morning programme on radio called the “Liam Nolan” hour in which the danger of smoking has been dealt with. We are trying to see what we can do to extend this form of propaganda and to have lectures in the schools.
I am not going to start the argument again with Deputy Ryan on fluoridation. I disagree with everything he has said about it. The overwhelming majority of opinion is that fluoridation is effective and non-harmful.
Deputy Dr. Browne referred to the question of whether or not there is enough appreciation of the need to treat mental illness just as a form of ill health and to eliminate the element of shame in regard to it. Other Deputies have made it quite clear that the whole atmosphere is changing. I shall be meeting the Mental Health Association shortly and I shall be discussing their programme with them. A good number of mental health associations have been established locally in different areas in order to give assistance to those who have mentally ill patients to create the right kind of atmosphere for the patients, to create the best possible conditions when they come back home, to get the community to accept the fact that mental illness is inevitable having regard to the enormous complexity of the human brain which consists of several billion cells. It must inevitably be defective on occasions. I think the miracle is that there are so many people who are mentally normal in view of the complexity of the brain.
I think I have dealt with virtually every important question that was asked but I shall have the debate looked through and if I find that Deputies asked some very definite and particular question with which I have not dealt I shall communicate with them. I should like to conclude by thanking the House for the way they have accepted the Estimate and for the constructive manner in which they discussed it.
