Dáil Éireann debate -
Thursday, 9 Apr 1970

Vol. 245 No. 7

Committee on Finance. - Vote 48: Health (Resumed).

Debate resumed on the following motion:

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 the 31st day of March, 1971, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain services administered by that Office, including grants to local authorities, miscellaneous grants and certain grants-in-aid.

—(Minister for Health.)

Dr. Gibbons

I referred last night to the position of dispensary medical officers and to the fact that those posts would be abolished under the new Health Act. I discussed the position obtaining in the more remote areas where it is difficult to get a doctor to work and I dealt with the question of salaries. The Minister has pointed out that it is proposed to give a basic sum as an extra inducement to doctors to work in those areas. This must be substantial because otherwise it will not be a sufficient attraction for doctors. The Minister mentioned a minimum income for doctors working in such circumstances and I consider this a good approach. I have no doubt he will take steps to work out with the Medical Association and Medical Union what would be recognised as a minimum salary.

However, there is another aspect of this work which I think has been lost sight of in the past and, to my mind, has contributed as much as anything else to the reluctance of doctors to work in remote areas. Under the dispensary system the county manager had the option, when a more congenial area became vacant, of submitting this area for a new appointment to the Appointments Commission and he also had the alternative that he could transfer a doctor from a remote area to the vacant position. For some reason most of the county managers have, for a number of years, refused to avail of this option and this has resulted in the situation that doctors working in remote areas now find it difficult to get transfers. It is absolutely essential that under the new Health Act doctors who are working in remote areas should have this built-in privilege of getting the option of transferring to a more congenial area should the opportunity present itself. If this suggestion is followed it will, along with the remuneration, go a long way towards solving the problems.

Another aspect of the doctor's life in those areas is the social one. There are many social disadvantages which I shall not list but which apply not so much to the doctor as to his wife and family. It must be admitted that the recent agreement between the Medical Union, the Medical Association and the Minister whereby doctors are entitled to four days off per month with pay is a big advance in solving the problem. This leave is welcome and doctors are very grateful to the Minister for having granted it. Probably it was not granted without some difficulty. Nevertheless, it is now a fait accompli and we are grateful for it. Again, unfortunately, there are parts of the country where it is almost impossible for the doctor to get somebody to stand in for him on those days. So, even though the leave is available in theory it is not in practice. At some stage we will be in a position to discuss these aspects of a doctor's appointment in more detail because I understand the Minister will be coming back to the Dáil with his regulations under the new Health Act.

The next thing that I should like to deal with is the FitzGerald Report. The Minister has gone into some detail in regard to this report, which is a good thing because it will give the public some idea and some understanding of what is in his mind. No doubt, throughout this debate, as throughout the recent general election, the approach of Deputies to this problem will be a purely local one, more or less as it suits themselves and their constituencies. Some areas will experience difficulties following the full implementation of the report. Other areas will find their hospital services improved.

The first thing that strikes me about the report is that if it had been offered to the country in 1932 before the hospital programme started nobody could have found fault with it. However, circumstances were different at that time and the Minister and the Department decided at that time on a policy which, it appears, will not be acceptable in ten or 15 years time.

Another aspect of the FitzGerald Report is that we are told that other countries are following the same lines. Some of the evidence and literature on which this statement is based has been named but unfortunately it is difficult to get details. Reference is made to what is happening in Scotland and Wales and to a report from Sweden. The reports in these cases should be made available, at least in summary. Perhaps it is wrong to voice an opinion on something that one has not read but hospitalisation in those countries is by way of new hospital structures; it is not a question of making better use of existing hospitals and the people in those countries find themselves in the same position as we would have found ourselves in in 1932. I just wonder is our position exactly analogous to theirs at the present time in so far as we have hospital structures on which there has been tremendous capital expenditure. Is it the intention in Scotland, Wales or Sweden to remove surgical facilities from hospitals where there has been tremendous capital expenditure? That is the kernel of the problem.

The Minister, dealing with general hospitals, indicates considerations which will influence him in deciding their location. He mentions first the financial possibilities. Nobody can disagree with him on this. He mentions the proper use of expensive equipment and the proper use of consultants. Those are two points on which everybody must agree. He makes the point that there must be a sufficient pool of work to attract specialist consultants. Again, he has a point here of which there must be unanimous acceptance. The Minister makes a fourth point—the question of reducing mortality. This is one of the points where disagreement arises and it is a matter in which it will be very difficult to get records for the purpose of proof. This evokes the question of the acute case going into hospital and the extent to which delay in getting the patient there will affect his chance of recovery. This point does not seem to have been dealt with so far by anybody for the obvious reason that it is so difficult to deal with.

Another point made by the Minister is the question of reducing the stay in general hospitals. I am sure that what the Minister has in mind in this regard is that a person having been operated on in a general hospital will be returned to the community health centre. This is a procedure about which I am doubtful. After acute surgery or very acute illness this will not work until after a fortnight or three weeks. It may, but what one gains on the swings one will lose on the roundabouts. I am convinced that if there is any suggestion of difficulty following the return of the patient to the community health centre the patient will be again sent to the general hospital and there will be this shuttling back and forth. Whatever may be gained by returning five or six patients to the community health centre in order that their stay in the more expensive hospital will be short, if one out of the six has to be returned to the general hospital extra cost will be involved in transport and in the longer stay in the more expensive hospital. In my view something will be lost. It may be suggested that the consultant will visit the patient in the community health centre. This may work on occasions but I do not think it will work on other occasions.

The next point that the Minister mentioned is hospitals where major surgery will cease to be carried out. This will be the controversial problem for the next few years. The Minister used the words "major surgical" and this right away brings up the question of difficulty of definition. What is major surgery? Even if major surgery ceases minor surgery will continue. Who will do the minor surgery? Under modern conditions and practice it is very difficult to make a distinction between major and minor surgery. I should like to hear the Minister ex-pound on this further.

The Minister refers to surgical facilities and says that surgical facilities cannot be taken in isolation. I am not absolutely clear as to what he wishes to convey by this. This is the kind of thing that agitates people. They believe that acute surgical facilities will be taken from them. If I understand the position correctly, there is a complete difference between the Minister's view in this and that of the people in the areas affected. It may be said that these people are not experts and are not competent to decide what medical services should be available to them. That may be so, but they are entitled to have some say. They must be assured that the services that will be available will be made available as quickly as possible.

The Minister makes the point that, by reducing outpatient services, he would hope to reduce the number of people coming in for surgical attention. I think there is a fallacy in that argument. As you increase the outpatient services you will inevitably bring in more people for surgical services. Granted they will be coming in for what is called "cold surgery"— hernias, cysts and so on. The surgical facilities about which we would be concerned would be surgical facilities for acute purposes. No matter how you organise your outpatient services you will find it very difficult to prevent acute surgical conditions arising. Take, for example, acute appendicitis. Most patients who develop that condition do not complain beforehand and have no reason at all to consult their doctor or to be sent to an outpatient service to decide whether or not this condition exists. Outpatient services will not prevent acute obstruction or acute perforation of an ulcer. People undergoing intensive treatment may get perforation. The outpatient service will not prevent this. The same argument applies to the injury as a result of a car accident or some game. As I see it, these are the acute conditions calling for reasonably urgent attention and no outpatient service will prevent them. The services to cope with these conditions should be continued in the county hospitals.

The Minister mentioned financial possibilities. He quoted a figure of £30 per week for a patient in a county hospital and £38 per week in a teaching hospital. If this is the evolution and 50 surgical beds are transferred from the county hospital to the general or teaching hospital the sum quoted would represent a difference of £20,000. If this is the evolution I think the Minister will have to consider whether or not the money would be better spent by putting an extra surgeon into the particular hospital. He would not cost £20,000. To take a more specific example, the difference in average between Roscommon County Hospital and Galway Regional Hospital, two hospitals it is proposed to run complementary, if the recommendation in the FitzGerald Report is implemented, will be £5 per week, which reduces the figure to £12,000. This £12,000 would provide a more than adequate salary for a second surgeon.

I shall not deal with the problem of extra ambulances, but the Minister in answer to a question here told us that the running of an ambulance in any of the western counties costs something like £3,000 a year. This did not include the cost of the nurses or, as will probably be the evolution, the cost of a male attendant as well. How many more ambulances will be necessary to take patients from Roscommon to Galway, Castlebar or Sligo? Again, more money will have to be spent on this extra transport. That could be devoted to paying a second surgeon in the county hospital in Roscommon.

The FitzGerald Report recommends that these hospitals should continue as county health services catering for medical and maternity patients. My view—it is the view of everybody interested in this—is that you cannot have a proper obstetrical unit without surgical facilities. No matter how patients are screened beforehand in this county health service no one can guard against complications, complications requiring surgical facilities. No matter how patients are screened the need for Caesarean section will arise for an unforeseen complication. Again, a fully trained anaesthetist will be required; so will a fully qualified obstetrician. Here, again, you will have a capital expenditure, particularly in the case of the anaesthetist, which will probably not be fully used. Again, there is, I think, some basis for continuing acute surgical services in these hospitals so as to make full use of the anaesthetists.

We who come from those areas have been accused of being emotionally involved with what is happening, but I am trying to consider this from a purely medical point of view. I have expressed the view before that I am convinced that people do not go to hospitals when they are ill; they try to get to doctors who will give them the best services. When I say this in public people admit that this is absolutely correct; they want the best services as convenient as possible to them, and they do not feel they should have to go further afield for them.

The next point the Minister dealt with was the Todd Report and here I am in complete agreement with him. When I first read the FitzGerald Report I expressed the view that there would be a real difficulty in keeping the hospitals open. Even if the Minister accepts half what is offered to him by way of reasons for keeping the present county hospitals open he or his successor may find himself in difficulties if the Todd Report is fully implemented because there it states that a specialist must have so many beds under his control or be trained in a unit with so many beds and as we do not have those units for training our people the doctors will not go to work in those units with insufficient beds and this could be a very definite problem. We may find that our hospital services are being eroded. We may have people running them but they will not be people of a high standard and this is a situation in which we do not want to find ourselves.

I recently saw a proposal to organise a training centre for orthopaedic surgeons so that they would be accepted on a reciprocal basis in Britain and America and here, again, the figure of 300 beds was mentioned. There is, however, only one unit in this country where they could get this training and if the same figure applies to other specialist training such as chest surgery or heart surgery I can see real difficulties arising, but this point of view is very difficult to get across to the public.

The Minister said that he wanted to centralise some of his services and decentralise others and the first department he mentioned was the diagnostic outpatient department; everyone is in complete agreement on this because this is one side of the service which should be more highly organised.

We need more consultants moving around the country. At present we have the orthopaedic consultants, ear, nose and throat consultants and the ophthalmologists but with more industry in the country we need skin specialists to deal with industrial dermatitis.

One aspect of our outpatient services needs to be changed and that is the appointment times. One finds that a patient requiring outpatient treatment in Dublin or Galway has to be at the hospital at half past nine in the morning. I think it is absolutely ridiculous that a patient from the country must be put in a car or ambulance early enough to be in Dublin by 9.30 in the morning. Out-patient services in Dublin and Galway will have to be provided later in the day. Of course, this may not be convenient for some of the consultants but it is something that will have to be done.

I agree completely with the Minister regarding the child health services as his first priority. This is one scheme which will certainly repay whatever is spent on it. I feel all the emphasis should be on detecting diseases and abnormalities and have them cleared before the child goes to school so there will be no imposition on the school-going period of the child for treatment as happens under the present school medical service.

I am not in agreement with the Minister that in built-up areas the examination should be carried out by someone other than the family doctor. I think this is a grave defect in the scheme. The advantage of insisting that the examination be carried out by a family doctor means that the family will be attached to a particular doctor. This is very important in centres like Dublin, Cork, Sligo and Limerick where we hear complaints from families who cannot get doctors at night. In most of the cases where complaints arise the families have no doctor and they never bother making an arrangement with the doctor until someone gets ill. When a doctor is disturbed in the middle of the night he says to himself: "Well, those are not my patients" and he is not prepared to get out of bed to see them but if they were his patients he would do so. If family doctors had to carry out these examinations a link would be formed between the family and the doctor and when an emergency arises he would, of course, attend them.

The Minister is trying to orientate people away from hospital but if children are orientated away from family doctors the orientation will continue and when children require treatment the parents will be more inclined to go to the hospitals and the clinics where the children received their examinations and avail of the services there rather than go to the family doctor. This would mean that services will be imposed on the hospitals which were never intended to be imposed.

When the first examination of infants takes place next October all the doctors carrying out those examinations will approach the cases with what we call a high suspicion index and anything they find in the slightest way abnormal they will refer to a specialist in the interests of the child but we do not have the specialist service to deal with those problems as fast as we would like and for this reason I feel that the assistant medical officers, who it is proposed to train to carry out this work, should be trained as semi-specialists to re-examine those infants and they should pass them through their hands on to the specialists. The point is made somewhere that so much time has to be given to the examination of normal children that there is not enough time for the examination of the suspected abnormal child. I feel that if this use were made of the assistant county medical officers, some of whom may need extra training, the service would run somewhat more smoothly.

Mr. Childers

I should say to the Deputy, because other people have raised it too, and, perhaps, we were not sufficiently clear about it, that the county medical officer or the assistant county medical officer for health will call up the family doctor of the patient and ask: "Would you take over this case?" He will also ask, if the child needs very urgent attention in hospital: "Would you like me to refer the child to hospital?" But the first option will be given to the family practitioner. I wanted to make that clear because the Medical Association naturally would be disturbed if it was not the case.

Dr. Gibbons

While accepting that, at the same time—I may not have made my point clear—in dealing with those examinations I said they must have a high suspicion index. Anything that is abnormal must be referred. Now, next October, following the referring of all those suspicious cases, you will be bogged down and I feel that there should be somebody in between to re-examine them and in that way there would be fewer cases referred to the specialists. There is nothing more worrying for parents than to be told that there is something abnormal about their infant and then to be unable to get attention for it in time.

The Minister dealt at length with the question of old people and I do not intend to say much about this. Under the Housing Acts it is open to local organisations such as the St. Vincent de Paul Society to build houses for old people. I feel that this aspect of housing should be developed if possible. One of the reasons why I feel it is not availed of is that the grant is not high enough. The Minister should approach the Minister for Local Government on this point. I know of a man who took his father and mother and his father-in-law and mother-in-law and provided two houses for them in a small village where they live convenient to him in their old age. I feel this is the ideal arrangement. Now if this housing accommodation could be acquired by some of the local organisations when, at some stage in the years to come it becomes vacant, other old people could be transferred there and looked after by the community.

I think the public health nursing scheme is excellent. I have seen it work in my own area. No doubt an extension of this service would be welcomed. It is something that will serve the people very well.

I do not intend to deal with the ambulance service at any length because this is something that will have to be debated in more detail as the FitzGerald Report is implemented. We will have to decide whether the cost of running ambulances, with the personnel and equipment used on them to take patients away from the present county hospitals, will save money or not.

The Minister mentioned seminars for doctors. This is a very welcome innovation. Those seminars are being conducted at present under one name or another. The Department of Health provide three-yearly post-graduate courses for doctors and some of the pharmaceutical companies run seminars. To have them run with the benediction of the Department of Health and to have time made available for the doctors to attend them more frequently would be a well worthwhile exercise.

The appointment of consultants was dealt with yesterday by other speakers. It was recommended that they should all be made by the Local Appointments Commission. This is essential. This matter has already been raised in some counties and the Minister pointed out that eventually it was his intention that all consultants will be appointed in a similar manner. I do not know whether any pressure has been exerted on the Minister since to come to a different decision but, if we start the health service with two-tier consultants, difficulties will be met in future years and future Ministers will find themselves in much the same position as the Minister for Education finds himself. He will have two-tier consultants and he will have to try to reconcile their interests and that will be a problem very difficult to solve. The Minister should stick to the situation as he has announced it, which is that there will be a unified system eventually for appointing consultants. I am sure it will not be overlooked, any more than in the case of the future district medical officer, that when people opt to come into the service, that when promotion is available and they have shown merit and shown that they are capable of conducting the work, they will get the preference for appointment. This will induce them to stay in the service and, in fact, to come into it in the first place.

I am glad to see that it is becoming easier to get dental officers. Dental services are unsatisfactory and, no doubt, the problem has been the question of getting dental surgeons, which seemed to be a matter of payment. The Minister assures us that this is now solved and we will be all grateful for this.

Mental illness is our biggest problem and much has been written and said on the changing outlook on what should happen with mental patients. We have moved now from the stage of the open hospital to the question of the early return of patients to the community. One wonders whether this is wise or how right it is. The patients live in a community, find themselves in difficulties with it and this is manifested as mental illness. They are removed from the community for a short while and then returned to it. One feels that this is hardly right. The patient is being returned to the circumstances from which he came. Perhaps it is right and that the fault is with the community. When one gives thought to this, one realises that that is probably the correct view. This brings up the question of training the community and dealing with the community rather than with the patient. In the past, mental illness in a family was considered a slur. Thank God, we seem to be getting away from that view.

One of the difficulties mental patients have in returning to the community is that those with whom they are intimate are not properly orientated to receive them back. This may be the kernel of the problem. It may not be so easy to deal with this. When a patient is removed to a hospital, or goes voluntarily to a mental hospital, a social worker, or better still the doctor who is looking after him, should have very detailed discussions with the family and discuss the whole matter of the patient's illness, point out to them the difficulties for the patient, how long he will be away, the situation that will exist when the patient returns, and how they should deal with him.

Before the patient is discharged there should be a further consultation with the family. The atmosphere for the reception of the patient should be made as acceptable as possible. It often strikes me about these patients that the doctor sees them before they go to the hospital and sees them afterwards in the hospital and their manner is completely different. When they are discharged they return to their former state. I have given some thought to this and I think this is brought about by the training which the doctors and nurses have received. They are able to create an atmosphere of acceptance and content in the hospital which suits the patient. On the other hand, in the home there is always worry and anxiety about the patient and he returns home from an atmosphere of quiet to one of worry and anxiety. I have not seen this view expounded by any specialist but it is my view from watching patients over a number of years.

I want to deal now with the screening services. There is a large demand for screening services at the moment and they are getting a lot of publicity. Some of them are very useful. Some time ago I read somebody's comment on them pointing out that out of about seven only two were particularly useful. I mentioned this at the time in one of the debates on the Department of Health. There is still work to be done on deciding which screening services are useful and which are not. RTE put out a programme one night dealing with screening for cervical cancer. The next day one of the newspapers carried an article which more or less cut the ground from under it. This has also been the situation in the medical literature for some time. There is a controversy as to the worth of this service. The patients will demand those screening services. They are expensive and they are time-consuming, but we will have to continue to make them available. If in future years it is proved that they were a waste of time, no fault should be found with anybody for spending money on them at present.

The last matter I want to deal with is probably the oldest medical problem in my constituency, that is, the question of Boyle Hospital. It is alleged with some truth down there that enough money has been spent on plans and on the scrapping of plans to have built a new hospital years ago. The Minister stated that in Boyle Hospital 48 places will be provided and that tenders will soon be sought for building. I hope that the next time we hear of Boyle Hospital it will be to the effect that the building of the extension or whatever it is proposed to build has started. If that is so I have no doubt the people in County Roscommon will be grateful to the Minister and say that he has certainly kept his promise to provide it.

Mr. O.J. Flanagan

The House owes a debt of gratitude to the last two speakers who have contributed to this debate, Deputy Dr. Browne and Deputy Dr. Gibbons. They spoke in a very informed and constructive manner. Their contributions as professional men will be of use to the Minister in moulding opinion on health matters. I want to thank the Minister for the manner in which he met public representatives to discuss the new health legislation. During the past 12 months he placed himself at the disposal of members of health authorities and county councils. The conferences he had in relation to all aspects of health matters in the Custom House will produce good results. I was present at one conference and I left it in an extremely happy mood realising that the Minister had studied and knew the problems to be faced.

He was most anxious to solicit the support and co-operation of members of local authorities in an effort to bring about a general improvement in the health services throughout the country. The Minister has shown that he is prepared to listen. Some of the difficulties which any enthusiastic Minister for Health is likely to be confronted with may come from the officers of his own Department who make what they feel are genuine and sound recommendations but which may not be practical for the men and women living in the country. He may then have to overcome the obstacle of getting the Minister for Finance to provide the wherewithal for improved services.

I am glad that so many Deputies are treating this Estimate very seriously. They are approaching it from the point of view that expressions of political opinion can be disposed of when they are discussing it. The health of the community has no place for political feelings. When tuberculosis, cancer or any other dreaded disease strikes it does not matter whether the person is connected with Fianna Fáil, Fine Gael or Labour. The House is discussing the Health Estimate in a very constructive manner and let us hope the views expressed by all sides will be a guide to the Department and that the Minister will endeavour to seek out what is best for the public. Every penny spent on health is well spent; it is a sound investment.

I hope I will be forgiven for saying that I am a believer in the British health service system. Of course it is very difficult to see how we could ever hope to have a health service based on the British system because they have a huge population and vast resources to meet the cost of the services. I sincerely believe that we should have a health service which would be such that no man, woman or child would be denied the best possible hospital, medical and specialist services. The Minister must be aware that the British health services have provided an outstanding service to numerous people in this country. Generally speaking, every family here has either relatives or friends in Britain and a great number of people have gone from here to live with their friends or relatives in England have had themselves registered with a practitioner, have been admitted to hospital and have had major operations. I know of at least 17 cases of people in my constituency who have had major operations performed in Britain under the British health services and which people at home could never hope to pay for. People from my constituency have gone to England and have returned here some months later and you would hardly know them; they were beyond recognition. Some people come back with spectacles or with false teeth, some return with new limbs which they have acquired, others from most successful operations which were performed entirely free of charge.

It is a sad commentary on our health services when even a small section of our people have to seek the protection of health services outside the country. All these services should be available at home. Health services here should be on a contributory basis. I presume that this idea has been considered by the Government. I venture to say that not one citizen would object to contributing to a proper health service provided he knew that the worry, inconvenience and great strain of meeting medical and hospital expenses would be removed.

In this regard I want to pay special tribute to the Voluntary Health Insurance Board who have acquitted themselves with distinction and who have eased the worries and burdens of tens of thousands of subscribers. I hope that eventually we will be in the position that the board's benefits will be extended to cover chemists' bills as well as the attendance of the ordinary family doctor. A national health service based on the principles of the Voluntary Health Insurance Board would certainly give us a greatly improved and more progressive health service. The health of our people is of vital importance and while many Deputies are speaking about the provision of hospitals, and the care provided within hospitals, as well as after-care, I would ask what steps are being taken by the Department to educate people to keep out of hospitals and to keep away from doctors?

If we have a public educated in all aspects of health then not alone will this generation but the next generation benefit greatly. Can the Minister or any officer of his Department tell us if the people have been taught what to eat, what proper foods to consume? The Americans are great eaters and they concentrate on what is on the table probably to a greater extent than any other people in the world. Look at the extraordinary death rate they have from cancer and from heart disease. One task that should be undertaken is to educate people in this matter of a proper diet, the proper types of food to consume. There are tens of thousands of people today consuming foods which are poisoning their systems. No effort has been made by the Department of Health to warn the general public regarding the danger of consuming foods which are a contributory cause of strokes, heart attacks or cancer.

In order to live well one must enjoy one's food but one must know what one is eating. The majority of our people are thoughtless in this respect: they seem to regard the body as something that can withstand every possible strain. When the body breaks down they seek to have it repaired by consulting their medical practitioner, but when one has a motor car with bald tyres and has an accident there is little use in having the tyres replaced at that stage. Now that new responsibilities are being placed on regional health boards it is time we took a serious view of educating healthy people about how to remain healthy. The Department of Health have an obligation to supply such information by publicity in schools and colleges and it is essential that in the future they concentrate on our schoolchildren.

A warning regarding overweight would be a most worthwhile exercise. There are thousands of people who never give serious thought to their weight. We all know that overweight can put an excessive strain on the heart. The heart is a most important part of the body; it is very delicate and complex and it is just not possible for a heart to remain healthy when the person is overweight. One could compare it to the case of a weak man or woman having to carry sacks of coal. However, to my knowledge, there has never been any publicity or warning on radio, television, in the cinemas or in our schools regarding this danger. People must be warned of the dangers of overeating and they must be educated in the matter of eating the proper foods.

We all know that white sugar could be described as poison because it contains a bleach to make it white and it has been proved to have a most detrimental effect on the flow of blood in the body. We all know that excessive eating of potatoes may or may not contribute to an increase in weight. We know that one cannot eat white bread and white flour to excess and remain in good health because the flour contains a certain bleach similar to that in white sugar. Why has there not been an all-out campaign against the excessive use of white sugar? Why not have a campaign for the consumption of wholesome brown bread as against the white bread manufactured with bleached flour? It is because vested interests are involved.

The Minister for Health knows there is nothing more dangerous than cigarette smoking. He has been warned about this by many Deputies in this House. I would much prefer to take small doses of strychnine daily rather than smoke cigarettes. Yet, one sees many of our citizens smoking from 20 to 60 cigarettes per day and they are certainly digging their graves. Perhaps they are doing this through ignorance but there is an obligation on the Minister for Health to warn the general public against cigarette smoking, irrespective of the interests of the cigarette manufacturers and of the problem of the Minister for Finance when it comes to balancing his Budget.

We must decide which is more important—the Minister for Finance seeking revenue from cigarettes or the saving of lives. Cigarette smoking is poisonous no matter what doctors may or may not say. It has been proved beyond all doubt in the United States, in Britain and elsewhere that there is an association between cigarette smoking and lung cancer. Should that in itself not be sufficient when we see such a dramatic increase in the number of deaths from this disease?

The Minister for Health has a duty to look after the health of the people; he has a duty to ensure that in our schools and colleges, on the cinema screens and on television and by every means in his power, the general public are warned of the danger of lung cancer. One way in which the incidence of lung cancer could be reduced is by encouraging people not to smoke cigarettes. I deplore the way in which television is used for advertising cigarettes. These advertisements may pay dividends for those who have a vested interest in the manufacture of cigarettes, but the fact is that thousands of our people are encouraged to do something deleterious to their own health. There is a duty on every Deputy and on every public spirited citizen outside to safeguard health. While advertising continues on radio and television the Department remains silent. If the cigarette manufacturers want to advertise their product, more power to them, but the general public should not be given just one side of the picture. The Department of Health should mount a suitable campaign on the lines of American and Canadian television telling the general public the association between lung cancer and cigarette smoking.

When will our people wake up to this danger? Will we go on allowing lung cancer to wipe out thousands of our people? We know that the chances of getting lung cancer are less if one does not smoke. Practical steps should be taken to alert people to the danger. Nothing is being done. No effort is made in this respect any more than any effort is made to reduce alcoholism. There has been no serious attempt to warn our people against the dangers of cigarette smoking. Let the people have a choice—give up cigarettes or else enjoy the pleasure of the cigarette, with the possibility of a speedy or lingering death from lung cancer. All the evidence is there, backed by statistics. It cannot be denied. The sooner the Department of Health gets to grips with this problem the better it will be.

Forget the Minister for Finance. Forget the vested interests. They can look after themselves. We have a responsibility for the health of the present and future generations. Unless we take a stand now the death rate from lung cancer 50 years hence will be out of all proportion. Steps must be taken immediately to discourage cigarette smoking and to cut out completely cigarette advertising. One sees young people and some elderly people, from whom one would expect better, advertising new brands of cigarettes. What would happen, I wonder, if someone went into Telefís Éireann to put on an advertisement: "Take strychnine in small quantities"? Would that advertisement be put on five or six times a night? Would it be accepted by the newspapers? I shall leave it at that. I urge the Minister to take steps to cut out cigarette advertising before the situation becomes such as to make such a step absolutely compulsory. If people must smoke there is less danger of lung cancer if they smoke a pipe. That has been proven.

I come now to diet. People should be advised on the kind of food they should consume. I have never seen an advertisement advising people as to what type of food they should eat. I have never seen an advertisement advising people to drink more spring water.

Mr. Geoghegan

It might be detrimental to some of them.

Mr. Tully

It all depends on what it is mixed with.

Mr. O.J. Flanagan

I am talking about pure water. People do not drink sufficient water. They are not encouraged to drink water. Is there anything cheaper than water? Cutting out sugar and eating brown bread are two things which make for good health. Again, people have never been educated into using honey. Honey is energy giving. The Minister must have on the shelves in his Department a booklet published in the United States of America giving the result of a survey which proved, beyond all doubt, that those who consume honey daily do not suffer from blood clots, strokes, heart failure or brain haemorrhages.

Why has there been no serious effort made to encourage our people to remain healthy? Why has the Department of Health allowed the Department of Finance to impose severe duties on certain health foods that are imported? If there are important health foods that are not manufactured in this country, the cost of these foods to our people should not be made prohibitive by import duty. There are import duties on sugar cane molasses, imported apple cider vinegar and other genuine health foods which are available here only for those who can afford to pay for them. There is, for example, the well-known cereal Fruesli on which there is a very heavy import duty. Why cannot the ordinary people in this country purchase this health food and other high quality health foods? They are not manufactured here and should be admitted duty free.

I raised this matter in the House some time ago and the Minister asked if I would supply a list of health foods which were subject to duty. I think I did but I cannot recall getting an acknowledgement. Perhaps the matter is still under consideration in the Department. I have referred in particular to Fruesli and kindred health cereals, to apple cider vinegar and sugar cane molasses which are subject to import duty.

I suggest that it would be a good exercise on the part of the Department of Health to endeavour to keep healthy people healthy and to put the younger generation on the right road to health. That would be much more desirable than allowing a situation to continue which would involve the expenditure of millions at a later stage on the eradication of disease. The people should be kept healthy from the start and then the elimination of disease will impose a lesser demand on the taxpayer. It is penny wise and pound foolish to encourage unhealthiness and then to have to spend millions on the elimination of disease.

How many people are advised to wash their hands before eating? I never heard the Minister or anyone in the Department of Health advising people as to the importance of this habit. Are people advised to wash their hands after using a public toilet? I never heard of the Department of Health issuing such a warning. A general standard of cleanliness is important in relation to health. I have not seen in this country notices in hotel toilets to the effect that people should wash their hands before leaving. These are very simple matters but they are very important. The Department should direct its energies to these matters.

I take very grave exception to the use of the expression "county homes" in the Minister's speech. In Ireland, in 1970, we still give official recognition to the county home which is associated with the union, the workhouse, the poor house. It is high time that that expression was dropped by the Department. County homes were built by the British about the year 1840 in order to house the Irish whom they were responsible for reducing to the state of paupers. They erected dark, gloomy buildings into which they pushed the poor, hungry, peasant Irish. They called these buildings county homes. The county home is a twin sister of the dispensary system which, thank God, will be disappearing partially next year. It took us a long time—from 1840. The county homes were used to a large extent in 1843 to 1845 and in 1847, immediately after the Famine. The buildings remain and still bear the name county home or workhouse or union. Thank God, in the constituency that I represent, if the word county home were mentioned in County Laois it would not be mentioned a second time. It is the one county in Ireland where there is no county home. There is a newly constructed building on the site of the old county home or workhouse. This building is known as St. Vincent's Hospital. It is a home catering for the sick and the aged. Thanks to all our efforts, over £250,000 was spent on modernisation.

There have been tours bringing people to Dublin Airport and bringing Dáil representatives to the Shannon Industrial Estate. It would be worthwhile to bring Deputies to the town of Mountmellick to see the institution which was built there at a cost of over £¼ million for the aged of that county. It is the most modern and up to date institution in the British Isles run by the Sisters of Charity of St. Vincent de Paul. Laois County Council is very proud of it and proud of everyone associated with it.

We have an obligation to provide for our aged; it is worth spending every penny that we can on them. There are buildings described as county homes which are no credit to this country. I have in mind one such building in the west of Ireland, which despite the substantial sums spent on it, still looks little better than it was at the beginning of the century. These workhouses, built by the British to house the paupers, should be wiped out. It is another badge of imperialism which should go. None of us can describe himself as a millionaire but there are certainly no paupers in the country today and I do not see why our old people should be asked to spend the end of their days in paupers' residences.

The Minister for Defence who is sitting in for the Minister for Health must know St. Brendan's Hospital in Loughrea. I visit this hospital frequently and I always avail of the nuns' generous hospitality but I sympathise with them because they have endeavoured, through their own hard work and the hard work of the Galway County Council, to improve that hospital and they have succeeded in making an old building look well and become as happy a place as possible for the old people who have to stay there, but the building is still an old one and I think the improvement of it can be described as penny wise and pound foolish.

I understand there is a county home in Sligo, although I have not seen it, which is well managed and well staffed but the general layout of the building makes it impossible for the staff to direct all their energies to making old people happy and comfortable there.

The contribution made to local authorities for the improvement of county homes and for providing alternative accommodation in certain classes for the year 1970-71 amounted to £190,000 and for the year 1969-70 it amounted to £160,000, but all that money would not build one institution for our old people. For that reason the Minister for Health may be correct in his endeavours to encourage relatives to keep old people at home but there are people with no relatives who have to spend their last days in institutions of this kind. There are old people's homes in Britain—and I think they were referred to by Deputy Browne last night—where old people are cared for under what can be described as hotel standards. Yet, in this country, there are still institutions where people are marshalled in to meals to sit around a big table and marshalled out again. For this reason I would like the Department of Health to encourage public representatives to visit the new old people's home in County Laois, which is laid out in the same fashion as our hotels.

Dr. Loughnane

How much was spent on it?

Mr. O.J. Flanagan

A quarter of a million pounds.

Dr. Loughnane

Three-quarters of a million pounds are being spent on the county home in Ennis.

Mr. O.J. Flanagan

It is a few years now since the £250,000 was spent on the Laois County Home and I would think for the expenditure of £750,000 that the Ennis County Home would be of the same standard. If Deputy Dr. Loughnane or members of the Clare County Council are ever in Laois they should visit the new county home and they will probably see there what the Ennis home will look like when it is completed. I know they will leave the Laois County Home very impressed.

The Department of Health, as I have said, are encouraging families to keep old people at home and that is the right thing to do. Old people are far better off in their own surroundings. It must be heartbreaking for old people to have to leave their own homes and go into institutions. They do not do it willingly. Many of them have to do it when the young people get married and new families come into the house and there is no place for them. This is a serious reflection on what we can describe as a social service in Ireland. We seem to be losing respect for the old. The moment they have to be looked after they are thrown out of the house and put into some institution where they will be looked after. We are all losing our sense of respect. Respect for superiors, teachers and parents is becoming less and less. Fortunately for me I will not be here in 50 years time to see what is happening then.

Minister for Defence (Mr. J. Gibbons)

Ah, the Deputy will.

Mr. Davern

If the Deputy keeps on eating the right food he will.

Mr. O.J. Flanagan

I will not be here in 50 years time but it will not be my fault—I will not die from cigarette smoking.

How are we to inculcate in our younger people something that was traditional in this country — respect for the older people—and encourage them to keep the aged at home if at all possible? Of course there may be aged invalids who require hospital treatment and hospital is the only place for them, but it is most tragic that healthy old people should have to end their days in an institution. I should like to see our people co-operating with the local authorities and with the Department of Health to keep old people in their homes for as long as possible and I should like to see the State provide domiciliary services and the required medical assistance. Many people who are in institutions must be subsidised to some degree by the taxpayer or the ratepayer and in the long run the State would be much better off if there was a proper domiciliary service and if substantial allowances were provided also, where necessary, for sons or daughters who must provide care, comforts or attention for old people. Our record in this country in regard to the aged is not one of which we can be proud. I hope and trust that steps will be taken to provide better institutions for old people who must have institutional treatment and who have no homes or relatives to go to. They are entitled to the best and most modern buildings and services we can provide. We have not done and are not doing this on a large scale. It is an investment that will eventually pay and it is a debt that we owe to the last generation and to those of the previous generation who may still be living. Our care of and attention to our old people is something which leaves much to be desired.

Reference has been made to the schools medical service. There are parts of this country where it does not exist. The present schools medical service is a complete and utter farce and the sooner we realise that the better. The service is not there except in name. I am glad to see that the Minister and the Department are now to make a long overdue effort to improve the health services for our children. We have thousands of children unable to get treatment because neither the specialists nor the hospital accommodation are available. There are parents of large families who do not qualify for medical cards, yet their children suffer from chronic bronchitis or a mild form of asthma and require drugs and medical care and attention every second week. Thousands of these children are being neglected in this country today. I have known dispensary doctors who have continued to attend children whose parents had no medical cards. There has been much talk about the dispensary system which is now going out. But Ireland owes a very deep debt of gratitude to the dispensary doctors. They have performed their duties in a way that has brought credit and distinction to the profession. No more than politicians, they were not all angels; but then where is there a community of 100 per cent angels? Not here.

Mr. J. Gibbons

In this House.

Mr. Davern

There is one anyway.

Mr. Tully

They may have been angels.

Mr. O.J. Flanagan

They may have been. The dispensary doctor has rendered outstanding service to this country. I pay a tribute to the dispensary doctors for attending free of charge poor people who, due to family circumstances, cannot pay £1 or £1 10s at every visit. Despite the fact that the local authority denies these people medical cards, the dispensary doctor still attends them. This has been going on, to my knowledge, in numerous dispensary districts because the dispensary doctor is dedicated to his profession and has an interest in the family and in rendering a valuable service. Is it not a very poor commentary on our health services that a doctor has to attend a patient free, gratis and for nothing while at the same time the patient is denied a medical card because of what is described as family circumstances, and that a doctor should be obliged to sacrifice his private practice and devote his time and energy to attending cases which should be paid for by the State?

We will not say anything about the medical card system on this Estimate because it is to be changed. There will be more uniformity in the allocation of the cards. Half the people of Roscommon will get them and almost half the people in my constituency will qualify for completely free medical services. More than half the people in the country are entitled to these services. That is why I say that all of us here, and particularly those of us who have any knowledge of the service, are envious and extremely jealous of the British health service. We have a duty to our people to provide them with the best service that can be provided, and I am not satisfied that we are providing them with the best. I am not satisfied that we are even going near to providing them with the best that can and should be provided.

In dealing with our dispensary doctors it is only right to say that for the greater part of their lives these men have been on duty for 24 hours of the day. The demands made by the IMA on their behalf were reasonable. Indeed, they cannot be described as demands, they were requests in justice. What is happening in areas where there are no doctors at present and what will happen in other areas when the existing dispensary doctors retire and are not replaced? I would be very interested to hear the Minister's comment on the number of Irish doctors working in Britain, Canada and America, and the thousands of Irish girls who are nursing in English and Canadian hospitals. I remember meeting no less than three Irish girls in the Bellvue Hospital in New York when I was visiting a patient. There may have been dozens of them there for that matter.

There is no hospital in Britain in which you would not meet Irish nurses. The same applies to our young doctors. They are in America, Canada and Britain. What steps will the Department take to remedy this situation? We have the material; we have the work; we have the patients for them. All we want is to bring them here and pay them.

There is something drastically wrong when parents have to approach a Deputy or some other responsible person and say that their daughter wishes to train and qualify as a nurse but in order to do so she must go to Britain because there is not a hope of her training and qualifying as a nurse here. Her name can be put on a waiting list and she may be called in two, three, four or five years. What does she do in the meantime? Does she waste her time? Does she lose her ambition? Does she change her way of life? There is an amount of red tape somewhere that should be cut drastically and quickly.

Many of our hospitals are understaffed. There is no point in saying that a partial staff on night duty in a hospital provides a sufficient service. It is as important to have a good standard of nursing service available at night in a hospital as it is during the day. The county manager tells us that the patients will be asleep, but what happens if they are not? If there are a few emergencies in a county hospital at night are not the complete resources of the nursing staff taken up immediately? What happens to the remainder of the patients when they ring their bells for attention?

I cannot speak for the Dublin hospitals because I do not know very much about them. I have nothing but the greatest praise and admiration for any Dublin hospital in which I was ever a patient. I know from my own knowledge and experience that country hospitals are not sufficiently staffed and, at the same time, the cream of Irish womanhood is engaged in the nursing profession in Britain and Canada. Why did they go? Why are so many of our young girls training as nurses in practically every general hospital in Britain—girls from every county in Ireland? They could not be trained at home. There are no facilities for training them. There are long waiting lists. Nursing is a calling. It is one of the noblest and finest callings. It is not a very well paid profession. Girls called to the nursing profession are there for the love of it and it becomes natural for them to be gentle and kind and sympathetic to the sick and the disabled. It is a wonderful calling.

When we have these people available why not train them and allocate them to the different hospitals, give them the necessary recognition on qualifications, pay them and have all our hospitals adequately staffed? I could never understand why this could not be done. I could never understand why an effort is not made to bring back some of our nurses who qualified in Britain and who are still there. The answer is that we cannot give them the same rate of pay as they are getting in Britain but if our people require a nursing service and if our hospitals require the personnel we have a duty to provide them and pay them. Therefore the fact that we are unable to pay them is no excuse because this is a necessary and essential service.

I deplore the understaffing of hospitals, the vast number of Irish girls who had to go away to be trained, and the failure of the Department to invite them to come back into suitable positions so that our hospitals would be fully staffed. It is a most painful experience to watch the county managers and the health authorities paring down estimates, particularly in relation to the health services, seeing if they can do with a nurse or two fewer in our district and county hospitals, and having consultations with the staffs of those hospitals to find out what is the smallest staff with which they can be run. How foolish can we be? The sick deserve attention and treatment. When people are paying for the upkeep of a general, regional, district or county hospital they expect services. They are entitled to the services, and there is a duty on health authorities, be they regional or local, to provide the staffs and the services for the people who are paying the bill. I submit the services in the past have not been provided adequately and I hope that the general overhaul to take place next October will enable these regional boards to get down to their job seriously and ensure that all hospitals within their charge will be adequately staffed day and night so that prompt and efficient services will be given.

I should like to pay a tribute to the section of the Department in charge of mass radiography. They deserve an expression of thanks and appreciation for the services they have rendered. Are people taking for granted that TB has been wiped out forever? Are we taking it too lightly and too easily? Are we asserting that there is no need for sanatoria? I suppose there is no need for so many sanatoria because TB can now be treated at home. There have been wonderful strides in the past 22 years. The people responsible for the medical counterpart of walking on the moon have made wonderful advances in the past quarter century. The back of the TB problem has been broken in this country.

On the other hand, is it right that we should rest on our oars? Should there not be more frequent check-ups on those who have recovered? Should we not still encourage frequent chest X-rays? Should we not at least alert people to the fact that, although we have modern drugs which have succeeded in lessening the incidence of TB, we still cannot take it for granted? It might be no harm if there was a reawakening in the Department in this respect because we still have a certain amount of TB. The danger is that we appear to be living in an atmosphere of "everything is all right, there is no need for care or precaution", and TB may again become a problem in years to come. That is why I emphasise the need for chest X-rays. It should always be in the minds of the Department and of our people.

When are we to have a scheme by the Department to cover chemists' bills? Reference was made to it last night by Deputies Browne and Gibbons. The cost of drugs and medicines has become stunning. "Stunning" is the word. Is it not high time that a scheme was designed suitably to cover medicine and drug costs? I have seen hospital and chemists' bills and one would have to be an Onassis to pay for them. I have sent them to the Department from time to time on behalf of country people and towns-people. I have been astonished at the cost of certain drugs which were required and I have seen people go in to solicit the sympathy of chemists to allow them to pay their drug bills by instalments. Of course, the chemists have to pay the drug manufacturers and this is the cause of embarrassment all round.

If a doctor prescribes expensive drugs and medicines and if the patient is not covered by a medical card, somebody must pay. It has reached a stage now when bills for drugs and medicines, which are prescribed and necessary, cannot be met. Is it outside the bounds of possibility for the Department to design some suitable scheme whereby, even on a contributory basis, the cost of drugs and medicines can be met? I must say that in this respect chemists in rural Ireland have been most helpful and considerate. I have seen also cases in which county managers have been generous to those not covered by the general medical services register: managers have agreed to pay a certain amount towards expensive drugs.

This cannot continue. This is not a proper service. This is why the unfortunate patients must seek assistance from county councillors, Deputies, county managers and others to pay chemists bills. It is not right. The patient does not feel independent. He feels he is under a compliment to everybody and, of course, he exposes himself as being unable to pay for what has been prescribed. Every person with commonsense and intelligence feels something should be done about this.

I should like to make a brief reference to our miserable failure to deal with the problem of mentally handicapped and retarded children. What is the problem? We have not even assessed where our mentally handicapped children are. Even if we had homes to put them into, we have no specialised staff to deal with them. What is the position of the numerous mentally retarded children who are at present in mental hospitals, where they should not be?

I wish to join with the speakers who have already paid tribute to the Order of Saint John of God for the specialised care that they have given to mentally handicapped and retarded children. An expression of gratitude must also go to those running homes such as Drumcar in Co. Louth and elsewhere for the work they are doing in this field. However, we must admit that we have not come to grips with the problem and it is my opinion that the Department of Health do not realise the gravity of the situation. Those connected with local authorities will know that in certain families in this country there is not only one mentally handicapped child but four or five such children many of whom are on waiting lists for admission to homes and institutions with little hope of being successful.

What an extraordinarily cross God has placed on the shoulders of parents of mentally handicapped children. We have a duty to lighten that cross, but to date the State has only scratched the surface of the problem. In addition to providing institutions and trained personnel to look after these children, there must also be provided specialized training facilities and such centres should be set up in different parts of the country. Where they are already in existence they should be extended and expanded so that whatever intelligence these children may have may be developed to the fullest extent and that at least they will be able to live an independent life as members of our community. Perhaps they have been blessed in many ways. At least, in the long run they are sure of more favourable judgment than those of us who have been blessed with commonsense and intelligence.

Can ayone estimate the anxiety, the worry and the additional expenses that are involved for the parents of mentally handicapped children, children who must have special home care and attention and who, later, require specialised training? One of the voluntary organisations—I am not sure if it was the Rehabilitation Institute— sent me a circular asking that I urge on the Minister for Health the granting of an allowance, without a means test, to the parents of mentally retarded children. In a home in which there is a mentally retarded child there must always be somebody left with the child and this, of course, means that the father and mother are completely tied down. I know that they submit to this voluntarily and with love for their children but could not some allowance be paid to them?

Our effort in providing personnel to man suitable institutions for our mentally retarded children is a poor one. Here again I salute the religious orders and others who are already associated with this outstanding work, but there is a lot to be done. The Minister and his Department should tackle this problem more enthusiastically and ensure that a proper survey is carried out to determine the exact numbers that will be involved. The county medical officers of health have been engaged in this work but, until such time as we have the institutions and the staff and until the proper training facilities are available, this problem will remain with us.

Mr. Childers

Did the Deputy have time to read my speech?

Mr. O.J. Flanagan

I did and not alone did I read the Minister's speech but I have been reading the speech of his predecessor and the speech of the Minister for Health before him. I certainly agree that there has been some progress. It would be very wrong of me not to admit that but the progress that has been made has merely scratched the surface. It is a very big problem and one which is engaging the Minister's attention but it will take some time to solve.

We also have the problem of the emotionally disturbed child who presents an entirely different problem from the mentally retarded child. This, also, is a field to which the Department of Health should devote a greater degree of energy.

I should like to make a passing reference to mental illness and mental hospitals. During the absence of the Minister I asked that the Department of Health discontinue the use of the phrase "county home". It is not fair to label an institution for the aged as a county home.

Mr. Childers

Surely the Deputy is aware that a great many of these institutions are called after saints but that people continue to refer to them as county homes?

Mr. O.J. Flanagan

No. We have broken that in parts of the country, thanks be to God.

Mr. Childers

I hope that will go on. They are all named after saints.

Mr. O.J. Flanagan

Clear reference is made in the Estimate to "county homes." Would it not be better to use expressions such as "homes for the aged" or to describe an institution as one suitable for old people? If the Department continue to refer to these buildings as "county homes" we cannot break that description in the country. County homes are the leavings of buildings provided by imperial resources for Irish paupers. It is time to get away from that. Let this be the last year we will have references in an Estimate to "county homes". In future let us refer to "homes for the aged" or "old people's homes". Most of the mental hospitals are called after various saints. When we are dealing with them in general, we usually refer to them as "psychiatric hospitals". The greatest advancement that has clearly been made in this country is in the approach to mental illness. The staffs of these institutions and the Department of Health have done good work by giving the patients more freedom, by encouraging them to be kept at home and looked after and cared for at home, by the setting-up of clinics in the various districts. The drugs available at present in this connection are a great boon. The old stigma of having been in a "mental hospital", the word "lunatic" and everything associated with it is going. I would say that another 20 years will finish all that type of approach.

The Department could do a little more to bring home to people the fact that, because a person becomes temporarily mentally disturbed, he or she should not have to carry the label of "lunatic" for the rest of his or her days. People are now flocking to these clinics. We have numerous voluntary patients. Our people are beginning to realise that a mental breakdown is as common as the common cold or pneumonia and that it is just an ordinary illness which can be cured. I wish to pay a very great tribute to the staffs of our psychiatric hospitals. I am glad the Minister saw fit, in consultation with ITGWU and any other unions involved, to give satisfactory consideration to the specialised work of our psychiatric nurses and their outstanding service to our community. Their training is first-class. Great headway must still be made, particularly in regard to alcoholics. Very good work has been performed in this regard but it still appears to be a problem. At no time should the Department endeavour to minimise the seriousness of the problem of alcoholism. The work of the various RMS throughout our country in these hospitals deserves the praise of this House and certainly it deserves our admiration and co-operation.

Apart from the Minister, I wonder if anybody thanked Professor FitzGerald for his report. We may be inclined to disagree with parts of it but undoubtedly it is a good document. The time has come for regionalisation. Professor FitzGerald and those associated with him deserve an expression of thanks and appreciation for the preparation and presentation of this report. I am sure the Minister is taking a look at the position of our county hospitals and is considering the holding of some type of inquiry before any hospital is degraded: I do not know if that is the exact word the Minister used.

Mr. Childers

Changed in function.

Mr. O.J. Flanagan

It is the same thing. When these health boards are established I do not think any of us will live to see the regional hospitals provided. First and foremost, we have not got the money and, secondly, there is little prospect of our being able to get the many millions, even billions, necessary for the provision of these regional hospitals. I do not dispute the idea. It is worthy of deep consideration.

I welcome the Minister's suggestion —it may even have been an undertaking—of a public inquiry at which all interested local authorities, medical people, and so on, will have an opportunity to make known their views before any serious decision is made by the Department in regard to our county hospitals. I wonder if the Minister is still determined to allow regional health boards to decide for themselves where the regional or general hospital within the region will be sited, or whether the Department will have the final word in the matter. Apart from the county hospitals, quite a number of our smaller hospitals are an outstanding asset to the community.

In my own constituency there are quite a number of hospitals. There is the county hospital at Tullamore—one of the finest in Ireland—the county hospital at Portlaoise and district hospitals at Abbeyleix, Birr and Edenderry. All these hospitals are efficiently run and command the confidence of the people in the areas. Whatever changes are made I hope that, in relation to Portlaoise and Tullamore there will not be any down-grading and that the district hospitals at Abbeyleix, Edenderry and Birr will be retained as suitable hospitals. However, this will be a matter for the new boards and will be dealt with when the time comes. I would emphasise to the Minister that there will be from every county very serious objections to the closing down or down-grading of our county hospitals at least until such time as there is a prospect of regional hospitals being erected. I cannot see this development happening during the lifetime of most of us here. May I take it that the Minister has accepted, with certain reservations, the FitzGerald Report?

Mr. Childers

Obviously, one has to modify to some extent any report one receives.

Mr. O.J. Flanagan

But in principle?

Mr. Childers

In principle, yes.

Mr. O.J. Flanagan

I do not think there can be any great difference of opinion.

Mr. Childers

The Deputy knows that I mentioned that an interim solution was greater integration between hospitals with ambulance services and consultants. That is another possibility.

Mr. O.J. Flanagan

It is not a simple problem and we all appreciate the difficulties. If difficulties crop up it is no harm to forewarn the Minister that we may be calling on him from time to time to help solve these problems and to assist in minimising any hardship people might be likely to suffer in the event of the changing of functions of any of the existing hospitals.

I should like to express my agreement with Deputy Dr. Browne's suggestion last night about the length of the medical student's course of study. Some effort should be made to reduce that course as it would be most regrettable if, because of the duration of the course and anxiety over examinations, young people were discouraged from entering the medical profession. It should be possible to reduce that course by a couple of years and it is a matter the Minister should investigate. There is a fine type of young boy and girl studying medicine. The tendency in modern times is to seek the profession that will yield the greatest financial benefit with the least possible study and in the quickest time. Bearing that in mind, medical students may not be encouraged to enter a profession that entails long periods of study and training and it is essential that there should be consultations with all the interests involved to try to rectify this situation.

The Minister was not here when I expressed my thanks to him for the courtesy he showed to public representatives on the occasion of conferences in connection with the Health Act. It is only right that I should let him know now that his courtesy was appreciated. He displayed an active interest in soliciting the views of members of health authorities and this was helpful both to the members of the local authorities and to the Minister and his staff. His job is a difficult one. As an Opposition Deputy and backbencher, the only criticism I have to make is that he is not going far enough and is not seeking enough money, but I know he will have a big battle with the Minister for Finance on this matter. However, he showed he had all his facts at his fingertips in his consultations with members of local authorities and I am sure he will be able to surmount any difficulties that may lie in the way of extracting from the Minister for Finance the necessary funds for health services.

Mr. Childers

I can hardly get much more than £18 per head of the population, including rates and taxes, this year.

Mr. O.J. Flanagan

Admittedly it is a fair sum but much work remains to be done in all aspects of our health services. We realise it is difficult to get sufficient money to achieve all our ambitions in this regard. However, that is the Minister's job. It is most regrettable that lack of finance should restrict our programme for better and improved health services. A serious effort can and should be made to provide our people with what they are entitled to—a complete, efficient and outstanding health service.

I conclude on the note on which I started: that I am a believer in the British health system. I realise that our financial resources are not available to the same extent but a new health system on a contributory basis, free for all except for the very rich, would be more satisfactory. There has been endless confusion and discontent in regard to the medical card problem and I am glad that steps are being taken to improve the position. I am sorry that the medical card system is not being discontinued. Perhaps in the not too distant future a scheme may be devised, either on a contributory basis or otherwise, by which this system could be abolished and a service provided for all. I would certainly prefer that type of scheme.

Our people have not enjoyed the fruits of a good health service in the past and we can only look forward to the future in the hope that it will bring us a more efficient and more effective health service, a service under which people will know that, even if they have not the money, they will not be denied medical or hospital treatment. People at the moment are fighting shy of hospitals, doctors and specialists because they have not got the money. That is a dreadful burden to have on people's minds and it is itself a deterrent to good health. It should be removed. There are quite a number here who would like to take a more revolutionary, shall we say, approach towards the organisation of a more up-to-date health service than we have. A service based on contribution is the ideal but, until such time as we can convince the Minister of that, we will just have to continue with the existing arrangements.

I am grateful for the courtesy shown by the Minister to the deputation of which I was a member. I thank the officials of the Minister's Department too for their courtesy. Over the past 30 years I have never found the officials anything but courteous. They are most capable and competent.

Mr. Tully

I am grateful to the Minister for the wealth of detail he has supplied. He did say he had only been a short time in the Department of Health and he has not got a complete grasp of all the facts. I say that he appears to have a very good grasp of most of them. His Department must have put a great deal of work into the preparation of all the documents he forwarded to us. I am very grateful to him because this makes our task very much easier.

It would be impossible to cover the entire Estimate in a debate like this. The fact that the Minister has been twice before the House already this year with a Supplementary Estimate and the Health Act means that he must be about fed up with the whole thing. I do not blame him for that. I shall try to cover the matters about which I feel pretty strongly as briefly as I possibly can. If they are matters on which the Minister feels he should comment I am sure he will let me have that comment when he comes to reply or at his personal convenience later.

Medical cards have been referred to here. I am sorry the final decision has not been taken with regard to the conditions under which medical cards can be issued. I am sorry the conditions are not being spelled out. This is something which should be done and the quicker it is done the better it will be both for the Department and for those who need treatment. The trouble is that the old arrangements laid down certain conditions and those administering the Health Act in the different health authorities adminster it according to what they think was intended. The result is that there are variations in the conditions laid down by the different health authorities.

One of the things I find most annoying is the fact that the gross wage is taken into account. When one remembers that in most health authorities all that can be considered is the rent being paid one appreciates how unfair the administration is. Consider the position of a man living in my own constituency who travels to Dublin to work on a building job. The distance may be anything from 20 to 30 or 40 miles. Counting overtime and everything else, he may have a gross wage of £17, £18 or £20 a week, or perhaps a little bit more. He may actually have less. He starts for work at seven o'clock in the morning to be on the building site at eight o'clock and he works until dark; at the moment that means 8.30 p.m. He has no opportunity of going to a café to eat. He brings some food with him and he makes tea on the site. He repeats that exercise in the afternoon or evening. He may travel in his own car or he may travel in a friend's car with some of his fellow-workers. He pays a fairly substantial sum for his transport. Out of his wage he pays social welfare and income tax. That may amount to £2 a week. He may pay a rent of £1, 30s or £2 a week. When he applies for a medical card he is told that his wage is £18 a week, or whatever it is. The rent is taken into account; that reduces it to £16. With £16 the local authority decide that he has a wage in excess of the amount a person may earn in order to qualify for a medical card. He is thereupon deprived of a medical card. His gross wage may be £18 a week, but that is not his take-home pay. It is reduced to £16 when one deducts £2 for rent. Deduct £2 for income tax and it is £14. Deduct another £2 for travelling expenses and the sum is reduced to £12. Social welfare and other payments will reduce it to £11. The worker may finish up with £11 a week, but he is told that he does not qualify for a medical card. I am sure the Minister has had numerous instances of this because he is now looking after a portion of my constituency. I am sure he has had plenty of complaints because I have had numerous complaints from the area of my county that the Minister represents. Sometimes I advise the people who complain that it would not be a bad idea if they got in touch with the Minister for Health since he represents the particular area in which they live and he can do more than I can; I can only make representations.

Mr. Childers

I have no responsibility.

Mr. Tully

But the Minister is the Minister for Health. This is the sort of thing that makes the present system of medical card administration a bit of a joke. There are people with incomes which should debar them from holding medical cards but, for one reason or another, they get medical cards while a neighbour with more children and a lower income does not get a medical card. I should like to see this kind of thing ended. If the Minister intends to make regulations with regard to income he will have to ensure that all expenditure is taken into account. There is one payment which is never taken into account. Newly weds are not able to pay for all their furniture at one time. The result is they have quite a considerable amount of hire purchase. These payments are not taken into account when medical card applications are being considered. Again, if a man builds his own house and is repaying a loan to the local authority, the local authority refuse to take that payment into account. They say he is a house owner and they therefore cannot take the £5 per week repayment into account. That sort of thing makes a joke of the whole system. I know that if the breadwinner falls ill a temorary medical card can be issued. That is not a big problem. If, however, a member of the family requires treatment, or the breadwinner requires treatment, the problem is a very big one.

Again, there is the problem where someone has to buy drugs or medicines over a long period. The Minister's predecessor and the former Minister, Mr. MacEntee, did make an arrangement which is still being administered, that in such cases the drugs and medicines can be issued by the local authority free of charge. Numerous local authorities are administering this scheme very fairly because it would be impossible for some people to pay for drugs and medicines.

Deputy Flanagan has referred to the question of chemists' bills. I should like to ask the Minister whether it is correct that one of the big snags about the issue of medicines is that the health authority can get drugs and medicines on contract on payment of a sum that represents about 52 per cent of the cost a chemist will charge for the same drugs or medicines across the shop counter. If it is correct, if some arrangement is not made to deal with that matter, it will become a very serious problem and will result in a terrific increase in the cost of drugs and medicines eventually to the taxpayer or whoever will be paying for them.

The Minister says that this year he has succeeded by way of the extra amount which has been given in confining the increase in rates to 2s in the £. We are one of the local authorities who are very conscious of the heavy drain that health services can be. For that reason we have always tied down the extra payments as much as possible. This year we saved 6½d in the £. The health services go up by 6½d and the 6½d will be looked after.

There is a problem on which I should like to have a comment by the Minister at his convenience. We require (a) at least one new ambulance; (b) there will be increases in the charges for various types of services this year; (c) there will be a substantial increase in wages for practically everybody in local authority employment. This is not taken into account in our estimate because we did not know what it would be. Will the guarantee the Minister has given about holding down to 2s in the £ cover these types of increases? I should like to know because it would mean an entirely new approach.

Something happened recently of which I take a very poor view. As the Minister is aware, negotiations are proceeding at present in regard to rates of wages for non-nursing personnel employed by local authority hospitals and by local authorities. One of the things which will affect this matter is the discussions at present taking place in regard to public service employees. Yesterday, I, as general secretary of a trade union, received a letter from the City and County Managers' Association. It was a copy letter, so, obviously, it had been issued to other local authorities also.

The letter informed me that the charges for emoluments were being increased by 25 per cent with effect from 1st April and the charges for meals served in the hospital were being increased to 7s. Do these people understand that the emoluments and meals for those working in hospital and living outside are wage affecting factors and that there is no point in people saying, before we succeed in negotiating a wage increase, that it does not matter what is done about that, that they will increase the costs to the personnel? This sort of stupid thing makes bad labour relations.

Did instructions come from the Department of Health to the City and County Managers Association in this regard? If the City and County Managers Association have got instructions, I say that the Department had no authority or right to issue them. Why should they issue such instructions? Who told them that they should give instructions as to how wages were to be negotiated? On what authority would they decide a matter which is between the employees, the trade union that represents them and the City and County Managers Association and the local authority? When the matter comes up for sanction a recommendation might be sent but an attempt unilaterally to increase costings on the employees of a local authority should not and will not be tolerated. I would be amazed if the Department of Health did this. If they did, the matter will not rest there. It will come up again before any agreement has been reached.

We have had discussions from time to time on the question of a reduced working week. Most people in hospitals have been working a 90-hour fortnight; that was reduced to an 85-hour fortnight. A suggestion had been made that that should be further reduced to a 40-hour week or 80-hour fortnight. Six or seven years ago the then Minister for Health, Mr. MacEntee, said that he agreed in principle that an 80-hour fortnight would be workable and because of the type of work involved was desirable. Since then a 40-hour week has been introduced in individual cases. If the Minister and the Department want to issue directives to the City and County Managers Association, they could tell them that the time is right for the introduction of a 40-hour week for hospital employees. In that case, perhaps we would be prepared to talk about other matters with them in a more reasonable way.

One of the things causing a great deal of trouble and about which a great deal of cod has been talked, of which, I am sorry to say, there is a little more in the Minister's speech, is the question of ambulance drivers, the ambulance service, and so on. Some people believe that there should be a fullyserviced ambulance attached to every Garda station. I heard a very responsible person suggesting a few years ago that there should be a doctor and a nurse with the ambulance—he did not suggest that there should be a clergyman there—and that the crew should be changed every eight hours. To implement such a suggestion would cost a colossal amount of money, apart from the fact that it would be for the most part a waste of time. The ambulance services in the country are still not satisfactory and there is not a uniform arrangement.

An ambulance driver drives his ambulance under strain because of the necessity to get the patient to hospital as soon as possible. It is most unreasonable that ambulance drivers should be asked to work a full day and, in addition, to be on call at night. The ridiculous situation continues that a man may be on duty all day and on call at night and may be called out at night and be out for three or four or five hours and then must attend for his normal work the following day without extra pay. There was an arrangement made some years ago, when it was found almost impossible to get ambulance drivers, who normally are very reasonable persons, to agree to continue to carry out these overtime runs for nothing. It was agreed that they would be paid for overtime runs. There were negotiations resulting in an extra 50/- per week being given as an "on call" allowance, with the strict stipulation that there would be as little as possible of this "on call" night duty. In spite of that we find in some cases that ambulance drivers never worked as much overtime as now without getting extra compensation for it. It has been suggested that the ambulance service should be regionalised in order to make more ambulances available.

There is one matter that should not be forgotten. The ambulance driver knows the area which he serves. In some cases the nurse accompanying him, and who may do an excellent job, does not know the area. The ambulance driver knows the area and how to get to the patient in the shortest possible time. I have met ambulances at one or two a.m. in the wilds of the country. The drivers knew exactly where to go. On one occasion I met an ambulance driver at 1.30 a.m. outside Drogheda who asked me on which of the two by-roads was the itinerants' camp. There was an itinerant woman who had to be taken to hospital. He knew where to find her. I said, "Well, they are usually camped on the upper one" and he said, "No, I think it is the other one" and he was right. These people have been trying for months to get the City and County Managers Association to agree to better pay and more reasonable conditions but no satisfactory result has been reached. A labour conciliation conference is to be held now to try to hammer out something. Ambulance drivers might decide one fine day that they will not take any more. We can all imagine what would happen if they were to say, what so many people say nowadays, that they have the power to stop all their services and they took advantage of the situation. I would certainly deplore any action of that kind but if agreement is not reached about their pay and conditions soon it is bound to happen in the same way as it happened to other services.

With regard to hospital services generally, we are not paying enough or giving enough good conditions to those employed in them. The public recognise that people employed in hospitals are dedicated people, but for that they would not be there. They are doing an excellent job, but we tend to treat them as though they were doing a nine to five, Monday to Friday job and for that reason a lot more consideration should be given to those employed in the hospital services.

I had a question down a few weeks ago about conditions for trainee nurses which the Minister was good enough to answer. However, I want to tell him that there is at least one very respectable hospital in this city where trainee nurses get all the dirty jobs, get two days off per month and are not very well paid. The Minister has said that there is a channel through which complaints can be made. They have tried to make their complaints but when this group of young girls attempted to complain to the doctor in charge of the hospital he merely said, "Well, what is the complaint this time?" He just did not want to hear about their complaint. If that is the way complaints are to be dealt with then we shall have to take another look at the whole system. I suggest the Minister notify all hospitals who train nurses of the minimum conditions of employment and wages.

Deputy Flanagan referred to the fact that girls have to go to England to train as nurses and even though there was a scarcity of nurses here a few years ago quite a number who tried to get training here were told that they did not qualify under certain conditions and they could not, therefore, be trained. Consequently, they went to England to be trained and perhaps they will come back. The Minister seems to think that there is only a shortage of nurses in one or two hospitals but there is such a shortage throughout the country that it has been found necessary to bring back married nurses. The Minister said he had arranged that they would get pay scales but the biggest snag about married nurses is the treatment they get from the income tax people. While the Minister cannot do very much about that he might talk to his colleague, the Minister for Finance, and point out that as long as married women are taxed on everything they earn over 30/- a week nurses will not be terribly anxious to come back to work.

The sooner the choice of doctor comes in the better but it is unreal to think that a choice of doctor is going to solve everything. The Minister said there will be certain out-of-the-way places where it will be necessary to pay a salary to doctors. I am sure he has heard of places like Nobber in County Meath and Crossakiel, where it was extremely difficult to get a doctor at all. A retired doctor came back to Nobber and with the assistance of the former Minister for Health he was appointed. The only doctor willing to go to Crossakiel lives ten or 15 miles away from the area and the result is that people have not got a proper medical service under conditions like that. The Minister will find that there are more areas than out of the way places where something will have to be done in order to keep doctors in the area. Doctors, being human, will go to where they are able to make a good living: they are entitled to do that. No doctor will live in an area where his income is going to be very small. While I welcome the Minister's statement that he proposes to bring in the choice of doctor very quickly the whole position has to be looked at in a way which will ensure that the position will be no worse than it is now and that there will be areas not being served by any doctor at all.

I have great sympathy with country doctors because for a few years I had the only phone in the area and on about three nights in the week I had to get up and call a doctor for a person who had become sick in the area. I have had the experience of phoning one doctor after another, up to a total of six who live close to me, and not finding one of them in, all six being out on calls. How a doctor does his normal work during the day and then goes out in the middle of the night is something which can only be explained by a doctor. The rota system might possibly get over this problem.

While I am prepared to agree that most doctors are dedicated men one occasionally finds, possibly because of his personality, a doctor who is extremely rude to patients, particularly poor patients. I hate to hear people complaining about the local doctor who did not have time to talk to them, or the doctor who snapped at them or the doctor who said to them, "Didn't I see a television aerial on your house? Surely you are not entitled to a medical card?" It is utterly ridiculous for people to carry on like that I do not know how it can be stopped except that with a choice of doctor scheme people will not go to doctors who bite off their noses, they will go to a doctor who will do them good.

The entitlement to benefits will have to be spelled out in a much better way. Last year, a farmer in County Cavan came to me with a bill from a Dublin hospital which Cavan local health authority refused to pay on the grounds that although the man had only a valuation of £40 he had a £30 valuation taken in conacre and this meant that his valuation was over £60 and he should therefore be able to pay the bill himself. He had a large family and he was finding it difficult to make ends meet. I suggested to the Department that conacre could not be counted as part of a man's original valuation because if it was counted the man who owned the land could also be ruled out under the same valuation and one valuation could therefore rule out two people and consequently the bill was paid. This year I took up a similar case with the Department and I was amazed to get the ruling that conacre does count. Somebody in the Department either changed his mind or somebody retired and a new person came in and the most recent decision I got is only a week old. A week ago, by phone, I was told that the legal adviser had advised that if a man had a place of his own and a conacre letting which brought the valuation to over £60 his wife was not entitled to free maternity payment. This is a stupid ruling——

Sir Anthony Esmonde

God.

Mr. Tully

——and I would ask the Minister to have a look at it. I shall give him the particulars if he requires them. This is the sort of thing which makes a laugh of the Health Act.

In regard to the question of the examination of children I am glad to see that it is proposed to have a very much better examination for children before school going age. I agree with the statement made by another Deputy that it is quite usual for children to have only one medical examination during their whole school life. We are told that the reason for this is that the number of people available to carry out examinations is not sufficient. Something will have to be done to improve that position. I have met a number of children who had been treated by their parents as being mentally deficient and subsequently at school examinations it was discovered that the children were slightly deaf. It took a very slight adjustment to cure them and they turned out in every case to be very intelligent children. There would have been a tragedy but for the fact that it was discovered at the school examination that they were not mentally defective but in fact just slightly deaf. This is one of the things which highlights the necessity to have school medical examinations carried out as often as possible.

The Minister says he has improved the position and I agree with him that the position particularly in regard to schools where handicapped children can return home in the evening has improved a lot. However, it is appalling to find in certain areas children of ten or eleven years of age who are on the waiting list to go into a school for treatment for mental handicap and whose parents have been told that the waiting list is so long that by the time their names are reached these children will be adults. Therefore, in effect, the parents are being told that there is no hope of these children ever getting treatment. That is a shocking situation. I remember one of the Minister's predecessors telling me a few years ago, when I suggested that more of the old buildings which were coming on the market could be converted into schools or schools-cum-hospitals that the big snag was not money and was not buildings but the shortage of trained personnel. He said then that it was proposed to improve training. Unfortunately it does not appear to have been pursued in the way he suggested it would be. We are still being told, as I was recently in regard to a little boy of 11 years of age, that there is a waiting list of seven years. Therefore, when that boy is 18 years somebody will get into the school, but it will not be him because he will then be over age.

Dental services for children have been referred to. I am not prepared to agree with the Minister that the position has improved a lot. I am not prepared to agree that dentists are being encouraged to come back from England because their services are being paid for here at almost as high a rate as in England. I have met dentists who have come back and they have complained bitterly that they are unable to make anything like the money they were making over there. Some of them say they were getting a fee-per-service so they were able to earn much more money. The younger men particularly feel that they could earn much more over there. Apparently here they are given a quota and they say that in England they were doing twice or three times that number in the same period.

It is something which is worth looking at. I am not an expert on it but I have been discussing it with these people. I know that the dental services here are pretty poor. The waiting lists are far too long in most local authorities. While children may get treatment and while it may be possible to do something for the mothers, the poor fathers must struggle on. There should be an effort made to do something more. A man who is paying social welfare contributions can get payment from social welfare towards certain dental services but I believe the amount is too low and the amount which must be paid by the parent if he succeeds in getting an appointment with a dentist is still far too high. He has to find more money than he can reasonably find. I would ask the Minister to try to have other arrangements made about that.

This brings me to the question of children who go to a doctor for examination. We tend to talk of children as youngsters not yet in their teens but in theory anyway people under 21 are the responsibilities of their parents. I have had complaints recently from various parts of the country that teenage boys and girls go to a doctor for attention and are sent by him to a specialist and the parents are not at any time told the result of the examination and the children themselves do not get any information either from the doctor or the specialist. I heard of a case of a boy who was sent along and he was told that he would have to have a course of injections. He has had two injections at six-weekly intervals and he does not know what they are for. He does not know what he should be doing or whether he is doing the right thing. When a minor reports to a doctor and there is a question of any kind of serious illness I feel the onus should be on the doctor to ensure that the information regarding that boy or girl should be passed on to the parents of the child concerned. It is only fair that this should be done. If this regulation were made I am sure doctors would welcome it. Perhaps some of them feel that they would be breaking confidence with the youngsters. This is something which should be done.

Public health nurses are doing an excellent job. My only regret is that there are not enough of them and that some doctors, particularly older doctors, tend not to be too anxious to use their services. They can do a wonderful job where the doctor has diagnosed and given instructions as to treatment. The public health nurse in many cases can take much of the weight off the doctors by doing routine work. I am afraid some older doctors do not seem to be terribly anxious to take advantage of their services. They prefer to go along themselves whenever it suits them. The nurses are building up quite a good relationship with the people in their areas. They are available when it may not be possible for a doctor to come.

The question of meals at clinics is one I have raised here and at my own local authority and elsewhere. Some local authorities find it possible to provide a light meal when patients come to the local clinic for examination and treatment if their stay is for a number of hours. Other local authorities are doing nothing about it. I know of patients who were collected in cars, mini-buses or ambulances at 8.30 in the morning and taken 20, 25 or 30 miles to the clinic. They had to stay there until lunch time and because of the many cases to be attended to were not treated or examined before lunch. They had to go away and come back again after lunch. Many of these people just have not got the money and if they had there are no facilities available to have a meal. Some of them may be unable to leave the bus and walk the distance to a café. There should be some provision made to have a meal made available to these people in or near the clinic. Some local authorities can do it and there is no reason why the others should not do it also.

I agree with the Minister that the question of where new hospitals are to be sited can become a political football. He comes from an area where there will be a pull between a number of hospitals, including one in the constituency which he represents. He will find himself, if he decides to take the decision himself, in a rather awkward position. If everybody wants to have his say and decide where the hospitals are to be sited then I am afraid there will be a lot of confusion. I would suggest to the Minister, therefore, that, when he is making a decision on this, some body should be set up to make the final decision.

What is to happen to the existing hospitals is a big problem but I do not think it is the greatest problem which affects us now because the Minister's predecessor said a few months ago that it could be 15 or possibly 20 years before the new hospitals referred to here would be erected. If that is correct, and I take it that since he was giving a reply to a Parliamentary question he was not taken unawares, there are far more pressing problems to be discussed on the Health Estimate than what is likely to happen to the existing hospitals which may not continue to carry out their present functions.

As we know, the British have dealt with the question of convalescent hospitals and made a very good job of them. Possibily, if we are alive when the system is operated fully here we may find that this is an excellent idea. The Minister might at some stage inform me how the staffing of the other hospitals is to be carried out, who will send the patients there, what type of patients will be sent there and by what type of staff will they be serviced. This is something which we should all know. It is very important.

The cost of the various hospitals has been mentioned here and, while the figures appear very high, I am sure the Minister will agree with me that they are artificially high because of the fact that in most hospitals there are continuous repair and maintenance jobs to be done and all the costings go on to the cost per patient. Is it not true that everything money is spent on in a hospital eventually finds its way on to an average figure such as the Minister has given? If that is not correct I should like to be told because, so far as I know, this has been the position up to now.

Deputy Flanagan talked about the wonderful old folks home they have in his constituency. An excellent one has been provided in Trim, called St. Joseph's Home. They have included quite a number of additional services there recently. It is an excellent place. It is a comfortable place. There is still one thing which I dislike about these old folks homes and that is that if two old people, a man and a woman who have been living together all their lives, go into one of those homes they must separate and may not see each other again before they die. Some effort should be made, similar to the effort made in other countries, to provide perhaps, at village or town level some type of accommodation in which those old people could live together for the rest of their lives. I was very impressed some years ago in Finland to find an arrangement whereby some people were not only allowed to live together but were also allowed to go out and work if they could find any work to do and come back in at night.

Deputy Flanagan was very irate about the references which he said people made to paupers and he said there are now no paupers in the country. The name does not matter very much but there are still unfortunate people who go into those old folks homes looking for a night's shelter. They are people who have no food and no money and nowhere to go. They beg along the roads and when they reach a place like that they ask for and are given a night's shelter. It does not matter what they are called. They are still in a very bad condition.

Deputy Flanagan also spoke about the necessity to provide the right type of food and said that the wrong type of food was killing people. The Minister made a very sensible reference to this. The people suffering from the effects of over-eating usually do not require the State to look after them. There are many people to whom over-eating is not their problem and, if we can succeed in getting the State to look after the people who are under-eating because they have not got the money to buy what they require, we will be doing a very good job. As to the over-eaters, on their own heads be it if they want to eat too much or eat the wrong foods. They are wealthy enough to look after themselves and get the right advice. I would be more interested in those who, through no fault of their own, are not able to eat enough, and, unfortunately, we still have too many of them in the country.

What happens to the old folks and why they should have to go into those places has been referred to by a number of speakers. Since I came into this House I have again and again referred to this problem. Unfortunately, the Irish have not got a great reputation for the way in which they look after their old people. Some people may find that, due to their family commitments, they are not in a position to look after their old people, but there are far too many people who want to live well themselves, who were reared by these old people—many of them prematurely old because they worked hard to try to give the young people a good start in life—and who are quite content to see their old parents moving into an old folks home and forget about them politely.

For a different reason from Deputy Flanagan's I go occasionally to visit some of these places and it is too bad to find old people there who complain that nobody ever visits them. This really seems to touch them. None of their friends go near them. Nobody they know comes near them and they feel themselves completely abandoned. This should not happen. After all, we are supposed to be living in a Christian country and we should do more for our old people than we are doing. I would suggest that some small flats should be provided for them or that they should receive an extra payment to help them to live in their own homes.

Another matter about which the Minister cannot do anything personally but about which he might have a word with his colleague, the Minister for Social Welfare, is the fact that if an old person owns a dwelling or has a vested council cottage or anything like that, automatically his old age pension is reduced by 5/- per week. To people here 5/- a week may not be a lot of money, but to somebody who is trying to exist on that amount per day, or a little more, 5/- is a big amount of money. This provision should be taken out of the social welfare code. The original idea of including it was good because it was probably to deal with relatively wealthy people who were able to wangle an old age pension. It is now working against people who have a roof over their heads and nothing more. It is too bad that they should have to forfeit 5/- per week. If that or a little bit more could be given to them it might encourage them to stay in their own areas where they would be much happier too.

We heard a lot of talk about heart disease and lung cancer. I often wonder —and perhaps the Minister could enlighten me—whether the figures now produced are as a result of the present medical knowledge rather than as a result of an increase in the number of people dying from those diseases. I am not terribly old but I remember the time when people died with what was called an inward pain. They just got sick and died and nothing could be done for them. Then it was discovered that there could be an operation for appendicitis and that they could be cured. Is it not a fact that, because people who become ill go to hospital or have a medical examination, it can be proved that they died of these diseases, whereas they died of them before and that was not known? It is an interesting point on which I should like to hear the Minister's comment because I feel there may be a certain amount in that suggestion. Is it not a fact that more detailed records are now kept of infant deaths and does this not have an effect on the figures?

Mr. Childers

Certification is improving all the time and this has created a distortion of the figures.

Mr. Tully

Deputy Browne spoke last night about cigarette advertising. Six, seven or eight years ago I seconded a motion which he had proposed asking the then Minister for Health to prevent large-scale cigarette advertising and to have a note on the cigarette packet to the effect that cigarette smoking could have harmful effects. The matter was to be looked into, and I am sure it has been. I know that cigarette advertising on RTE is being phased out. I know also that the revenue from tobacco is so high that it must have a big effect on what the Government do about it. Perhaps if we or some other party were in government we would have to look at it in the same way.

It seems to be definite now that a lot of lung cancer is being caused by cigarette smoking. I would have a way of dealing with it which would not be very popular. On the other hand, I believe that many of the diseases which we blame on cigarette smoking may be caused by other things, such as inhalation of diesel and petrol fumes. One has only to walk in O'Connell Street to find that it is almost impossible to breathe because of the pumping out of fumes at ground level by traffic. This is a matter the Minister might discuss with some of his colleagues in an effort to try to ease the situation. Even in the country, if one is following a heavily-laden lorry one sees the diesel fumes being poured out all the time and one finds it sickening to breathe it. It might be a very good idea to tackle this matter seriously.

When speaking about hospitals earlier, I forgot to mention one problem about which the Minister might do something. In various hospitals in the country I have had complaints from patients that the amount and the standard of the food given to them is not sufficient. I agree that individuals differ and that what will be plenty for one person might not be nearly enough for another and that there may be people who feel they are entitled to more. Sometimes a doctor may not think it good for some patients to get too much. On the other hand, it would be a shocking thing if in old folks' homes and in hospitals people were not getting as much food as they should be. If we are to cut costs that is not the place to do the paring.

I should like to refer briefly to the question of drug addiction and alcoholics. Alcoholism have been referred to but my main concern is with drug addiction. I do not think we are doing enough about it. The Minister may say he has been but a few months in the Department and that he has not had an opportunity. He may say he is awaiting a report. The week before last a horde of "weirdies" descended on a seaside village and although they did not do much damage, apart from breaking into a house or two, when they left we could have had a sale of syringes. All over the beach these people threw away syringes which they had used and it is obvious there must have been great use of drugs among them. Something must be done about it because at the very least the descent of hordes of these people on a holiday resort will ruin it because people who come along and see this kind of thing will not return.

It is all very well to talk about the permissive society but I believe that in this country there are certain types who have been getting away with murder, being allowed to do and say things which would not have been allowed a few years ago. Many of those people in a few years will perhaps be as critical as I am of them now, and this makes it all the more annoying. It is a matter into which the Minister should put as much energy as possible because if the drug traffic takes a hold here we are in for serious trouble. The people who go around using drugs freely encourage others because many of them give the impression to the youngsters that they are not "with it" unless they participate in drug taking.

On the question of alcoholism, I do not regard it as being as serious as some reports suggest. It is more or less a question of being able to afford it. We do not find many poor people going around "in the rats" because they could not afford it. Advice might be the best way to deal with alcoholics.

Reference was made to increased demand for hospital treatment. When the last Health Bill was introduced the suggestion was made to doctors that awkward patients should be sent to hospitals to get them off the rounds, so to speak. The fact that this has been done has helped, evidently, because the number has dropped.

An excellent job has been done during the past few years in the mental hospitals and I think the setting up of clinics for the treatment of people not so seriously mentally disturbed can be largely thanked for it. It has meant that hundreds of people who might otherwise have spent the rest of their lives in mental hospitals have been rehabilitated into ordinary life. More attention has been given to the social treatment of mental hospital patients. They are not being treated as they were in the past.

For instance, not so many years ago I had experience on a hospital board where the women patients, even those who were able to go out and about town, were issued with shawls. We soon put a stop to that. They were issued with ordinary clothing. A new doctor took over and he helped considerably. The women were allowed "hair-dos" and so forth and it helped to build up their egos. The result of all these things was that the number of patients in that hospital dropped substantially in a short period. The treatment of mental patients as simply sick persons, not outcasts, has been a tremendous success. If we continue to treat them just as sick persons who before they became ill were exactly as everybody else and who after their illness will return to that status, we will be doing a great day's work. These people are no worse and no better than any other patient and that is the way they should be treated.

I wish to thank the Minister and the Department once more for the courtesy with which they have dealt with me. I may object to the system and in many ways to the way in which it is being administered—I have been critical of the system here today—but I give credit where it is due. Some Deputy said the Minister is the most courteous member of the Government and with this I agree. He has always treated me with the greatest courtesy. I wish also to thank the Department officials who went to a lot of trouble to prepare the material we have before us today.

Sir Anthony Esmonde

The figures in relation to the Estimate are of considerable interest. I have spoken in this House on many Health Estimates down through the years and I have always maintained that the 1953 Health Act around which all health administration revolves was not a success. Each subsequent Health Estimate introduced here proves that that is so. I am sure that every Deputy, regardless of his political views, wishes to see the best health administration that it is possible to have.

The Estimate is for £37 million. Of that amount £32 million is for the purpose of financing health administration based fundamentally on the 1953 Health Act. That is an increase of practically £5 million over last year. That is the estimation made by the Minister. One appreciates that the Minister is trying to alleviate the over-all charges imposed on ratepayers who are producing about £2½ million. I am not satisfied that this is anything other than a palliative. It is quite obvious that as we administer health, these charges will increase and it is a poor outlook for the many health urgencies of the present day that of this comparatively large sum less than £5 million is available for the many facets of health which it is desirable to improve, expand and increase in enabling us to keep in line with the modern age.

I sympathise with the Minister for Health. I do not know whether he is an indoctrinated supporter of the existing health administration but he certainly shares the burden, the difficulties and the doubts that have been shared by all his predecessors in trying to administer a health service which, to my mind, is unsuitable and unsatisfactory as well as being morally unsound.

I have always held the theory that it is the responsibility of parents, in so far as they are able to do so, to look after those for whom they are responsible, their children and dependants. The tendency in health administration, as a result of this legislation, is to try to put that responsibility as much as possible on the State. If that responsibility is put on the State it simply means that the private lives of people are being handed over to a certain extent to administration bureaucrats. I do not use that in any derogatory sense but these people are simply trying to administer something which, fundamentally, is false to our interests.

There are many things that we should do and many things that we would wish to do in relation to health legislation but there is only a sum of about £5 million available for that purpose. In present day circumstances and since we are trying to make up for a backlog of work that should have been done during the years, £5 million is a negligible sum. It is for that reason I suggest that the Minister should take an overall look at the health administration. I am not now advocating legislation but merely referring to it. Recently the Minister came to the House with legislation the thinking behind which was to lighten the administration by locally centralising it and creating bigger centres under the illusion given to him, no doubt, by his advisers and that he would reduce the expenditure on administering the health services.

It is quite obvious that this change in administration from a county to county to an overall administration of three or four counties was bound to meet with strong opposition in many centres. Nobody likes to give up the authority he already wields and, to some extent, the Minister was faced with this great difficulty. The people opposing the legislation asked "Why should we have everything taken out of our hands because even if we have to accept this legislation we must still retain a certain local administration?" The Minister bowed to that because he must accept popular opinion. He was faced with the fact that county to county administration was by no means dead and if he had chosen to guillotine it altogether he might not have got a satisfactory administration. He might not have got the enthusiastic support from those from whom he was seeking support and, therefore, he had to negotiate.

What is happening now is that this new administration which is being set up will be a continuance of the existing administration. Therefore, I am endeavouring to point out to the Minister that what will happen is that this Estimate for £37 milion may not be sufficient. Neither the Minister nor any of his advisers can give any guarantee that the expenditure will be contained within that sum. I have always maintained that a very high percentage of the cost of health falls on administration itself. We now face not only the expense of a county to county administration but we are to have provincial administration also and this, to my mind, makes nonsense of the £32 million provided in the Estimate for administration. In my opinion the Minister will be back here during the spring with a sizeable supplementary Estimate. Everybody wishes to do what is possible to ensure that everybody gets the best possible health service but the tragedy is that in any new legislation the bill for administration is piling up all the time. Again, to get back to the Estimate, a sum of only £5 million is available for any good medical social services which it will be necessary to introduce and which must be introduced if we are to keep in line with existing services in other countries.

Progress reported; Committee to sit again.