It is proposed to discuss motion No. 4 with this Vote.
Committee on Finance. - Vote 48: Health.
I move:
That a sum not exceeding £58,028,000 be granted to defray the charge which will come in course of payment during the year ending on 31st day of March, 1973, for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an Ard-Chlaraitheora) and certain Services administered by that Office, including Grants to Health Boards, miscellaneous Grants and certain Grants-in-Aid.
Those Deputies who read my Estimate speech for the financial year 1971-72, together with the notes on the work of the Department, circulated some weeks before, will have noted that my general statement referred to what can be described as on-going policy development continuing during the present year. In the circumstances I do not propose to speak at great length, but to refer to aspects of the health service that need special mention.
The choice of doctor scheme has now commenced. The completion of the health administration system is described in my brief on the resolution for the formation of the regional hospital boards and Comhairle na nOspidéal.
I have also circulated for the third time a statement indicating the breakdown of the increased cost of services for this year, now totalling £86,550,000, showing an increase in cost of nearly £13 million. In this document will be found the cost of the health board programme management structure costing an extra ½p in the £ to the ratepayers and let me observe that the cost of administering the health services represents 3½ per cent of their total expenditure.
Deputies will note that under subhead G—main expenditure for my Department—is listed mainly the payment of grants to health boards as well as balance of grant for previous years.
As Deputies will recollect, I announced in the Dáil last February that the Government would be making available in the current year a special grant additional to the statutory grant so as to limit the increase in the health rate for 1972-73. This support from the Exchequer not only obviated the need to rate in 1972-73 for increases which arose in the year 1971-72, but ensured that, overall, the increase in the rate struck for health for 1972-73 as compared with the year 1971-72 would not be greater than 30p in the £ in any area. If the Exchequer had not assumed responsibility for this additional expenditure the average increase in the health rate would have been 64p in the £, which comprised 16p arising from increased remuneration of health staff and increased costs of medicines and other materials during 1971-72 and 48p in the £ towards the increased costs in 1972-73.
The Government's decision to limit the impact on the rates resulted in supplementary grants being allocated to areas where it was needed to the extent of approximately 9 per cent in excess of the statutory grant of 50 per cent. When it is considered that similar measures to limit increases in health rates were taken in respect of the years 1970-71 and 1971-72, it will be clear that the contribution from the Exchequer in recent years for this purpose has been notable.
Here I must mention also that, in addition to these grants, the Government are again making available under subhead K.1 an Exchequer contribution to the Hospitals Trust Fund to supplement the limited moneys available from the fund to meet the revenue deficits of the voluntary hospitals, which arise from the shortfall between the capitation rates paid for patients and the actual cost of the treatment.
In 1971-72 it was necessary to increase the subvention from £7,900,000 as estimated for at the commencement of the year to £9,400,000—an increase of £1,500,000. This arose from the increased remuneration paid to hospital staff and the rising costs of medicines and supplies. In the current year there is provision for a subvention of £7,750,000 to meet these revenue deficits. The reduction is due to an increase in the capitation rates payable by health boards for the treatment of eligible patients under the Health Acts. The revision of capitation payments is necessary for the purpose of maintaining some degree of balance in the normal income of the hospitals relative to running costs. The additional charges falling on health boards in the current year are fully absorbed by increases in the grants from the Vote under Subhead G, and local rates are not affected.
If we take into consideration the statutory grant of 50 per cent of health expenditure and the rates relief grant, and add the portion of the Agricultural Grant which might be attributed to relief of the health rates, that is to say about £9 million, we will find that the Exchequer meets over 70 per cent of health costs. In addition, the subvention to the Hospitals Trust Fund of £7.75 million, to which I have just referred, also benefits the contributing rating authorities by enabling the health boards to obtain the services of voluntary hospitals on a basis of charges considerably below actual costs.
The expenditure on our health services is very considerable in the context of our national resources. I have explained on previous occasions that, having regard to its high staff content, it is especially sensitive to rising rates of pay and being a constantly developing service it is influenced by commodity costs. In those circumstances, our objective must be to obtain the best value for money by using our resources in the most effective way possible. It would not be realistic to seek to limit expenditure by resisting the growth and improvement which are common to all developing communities.
The document circulated to Deputies in connection with this Estimate contains statistics of births, marriages and deaths covering the period 1966 to 1971. The death rate in 1971, at 10.6 per thousand population, is below that for the previous years shown and is, in fact, the lowest rate on record for this country. The death rate from heart disease declined slightly and the death rate from cancer, all forms, in 1971 was the same as in 1970 and practically the same as 1969. Unfortunately the death rate from cancer of the lung continued its upward trend, and is now 33.3 per 100,000 population.
Deaths from tuberculosis continue to decline, but despite the marked decrease in the number of tuberculosis cases within the past 20 years or so, it would be a mistake to become complacent about this disease and continual vigilance is required.
The infant mortality rate in 1971, at 18 deaths per 1,000 live births, was the lowest on record, as was the maternal mortality rate, at 0.16 per 1,000 live and still births.
There is a separate table showing the expectation of life at birth and at 50 years of age, which shows that our figures are on a par with the life expectancy figures in Great Britain and Northern Ireland.
I turn now to the increase in the birth and marriage rates, which are deserving of comment.
There were 67,752 live births registered in 1971—an increase of more than 3,300, or 5.2 per cent over the figure for the previous year.
In 1971 there were over 21,600 marriages registered, the highest number since the foundation of the State, representing an increase of more than 40 per cent over the figure for 1961.
At the same time, the age at marriage has been falling. In over 60 per cent of the marriages registered in 1969 the brides were less than 25 years of age. The corresponding figure for 1959 was 46 per cent and for 1945-46 was 36 per cent.
A consequence of earlier marriages is, of course, earlier age at maternity. In 1971 the average age of mothers at maternity was 29.4 years, whereas it was 31.5 years in 1961.
A significant development in recent years has been a reduction in family size, with the result that an increasing number of births are first or second births while the proportion representing higher order births is declining.
A large part of the recent increase in births has taken place in Dublin. This, combined with the virtual disappearance of domiciliary confinements and the closure of a number of small maternity homes, has resulted in considerable pressure on accommodation in the Dublin maternity hospitals. Officers of my Department and representatives of the hospitals concerned have had regular discussions in order to keep the position under constant review. Steps which have been agreed and are in process of implementation will, it is hoped, deal adequately with the situation so far as we can foresee it.
The setting up of the new organisations specially concerned with the hospital system, which I will refer to in more detail in relation to the motion proposing the approval of draft regulations, should be of great significance in advancing the rational development of the hospital system on a basis which conforms with the logic of the Report of the Consultative Council on the future of the Hospital System. In the meantime some significant advances have been made on the lines indicated in that report:
—In Dublin, St. James's Hospital and James Connolly Memorial Hospital have been brought under new joint boards set up under the Health (Corporate Bodies) Act, 1961;
—Discussions are proceeding aimed at the closer co-ordination of the work of the three cancer hospitals in the city;
—The development of the major cardiac surgery unit at the Mater hospital has involved participation of consultants and para-medical staff of the Federated Dublin Voluntary hospitals, and joint administrative arrangements regarding this arrangement are being worked out;
—In Cork the planning of the 600-bed regional hospital has been completed and tender documents were issued to prospective contractors at the end of March. Tenders are due to be received by 5th July and it is hoped that building work on the project will commence in the autumn;
—In Limerick discussions have been proceeding between officers of my Department and the Mid-Western Health Board to determine an order of priorities in the further development of the regional hospital. It has been agreed to proceed immediately with a third operating theatre. The planning and execution of a 50-bed paediatric and a 50-bed psychiatric unit, a new laboratory, and expanded out-patient facilities is to be expedited;
—In Galway agreement has been reached about the integration of the Regional and Merlin Park hospitals;
—Planning of the new general hospital at Tralee is also proceeding.
The House should appreciate that in the hospital field, as in health care generally, we are dealing with a dynamic situation presenting patterns of need which are changing more rapidly than is generally appreciated. The advances of medical science are a major factor in the situation—paradoxically, while these advances make it possible to deal with a wider range of problems they increase the volume of longer-term demands on health care services through the survival of those with continuing defects and the increase in the numbers of people living to a great age with inevitably heavy demands on health and social services. There are many other factors influencing the situation and these call for close study in which it is expected that the Medico-Social Research Board will play a significant part.
To illustrate the rapidity of change in the pattern of demand the figures for acute hospital admissions, excluding psychiatric and geriatric hospitals, are revealing. The following are the figures per 1,000 of the population for Ireland and Great Britain for 1963 and 1969:
|
1963 |
1969 |
|
|
Ireland |
101.2 |
119 |
|
Great Britain |
90.2 |
100.4 |
The disparity between our figures and those for Great Britain is reduced when account is taken of their waiting list, amounting to 10 or 11 per thousand of the population. These figures emphasise the need for more effective use of out-patient services, for all possible steps to reduce patient stay in hospitals and for better community geriatric and other services so as to prevent or reduce the demand on hospital care. The regional hospital boards and the health boards will have a key role in these developments.
Capital expenditure on hospitals in the financial year 1972-73, though competing with the need for increased capital investment in other areas of the public sector, is expected to reach a figure of £5¾ millions. This level of capital expenditure in the hospital field represents a considerable increase on preceding years and reflects a greatly accelerated rate of improvement and development of general hospitals and special institutions and services for the mentally handicapped, the aged and the mentally ill.
Lists have been circulated to Deputies giving details of hospital projects completed since 1st May, 1971, projects under construction on 1st May, 1972, and also projects that were at tender stage or at an advanced stage of planning on the same date. These lists give an indication of the variety and extent of hospital projects being implemented.
I have, on various occasions since I became Minister for Health, emphasised my belief that the soundness of the whole edifice of our health services is dependent on the primary care available to the individual. The last year has given me the opportunity to introduce two important measures which, I hope, will facilitate the future development of the family doctor service.
Firstly, I have established a consultative council and given it the task of advising me as to how I might go about putting the family doctor in the position where he can take full advantage of up-to-date medical knowledge so that his patients can benefit to the greatest extent possible. Obviously its findings will be of great significance in the field of health planning.
Secondly, the dispensary system has been brought to an end in the Eastern Health Board area and has been replaced by a choice of doctor scheme. As the House is aware, a similar development will take place in the remaining health board areas on 1st October next.
The first claims from doctors and pharmacists participating in the new scheme are now being processed. It is far too early to make an accurate assessment of the extent to which our earlier assumptions will be borne out. There are indications, however, that where some doctors in the Dublin area are concerned, the rate of consultation is significantly higher than anticipated, and considerably in excess of the rate of visiting indicated by surveys carried out elsewhere. It is not clear why this should be so and it may be that circumstances peculiar to the Dublin area are a contributory factor or that patients are seeing the doctor of their choice initially more often than would be usual particularly since the majority of the visits are at doctors' surgeries.
There have also been some cases of what appears to be exorbitant prescribing. The rate of prescribing is, needless to say, something which the doctor himself determines, and not the patient. There is, of course, no question of interfering with the doctor's discretion to prescribe whatever medicines he thinks appropriate to the patient's condition, but since public expenditure is involved, I have a duty to request that medicines should not be excessively or unnecessarily prescribed. The high rate of visits will also be the subject of careful examination.
The downward trend in the numbers of in-patients in our psychiatric hospitals continued during the past year. On 31st December, 1971, there were 14,922 patients, a reduction of 470 in one year. In the 5 years 1966 to 1971 there has been a reduction of 2,137, or 12.5 per cent, in the total number of in-patients in psychiatric hospitals. There must, however, be ever-increasing emphasis on out-patient services, community nursing services, social work services, short-term psychiatric units attached to general hospitals, hostel accommodation and rehabilitation.
As a further step towards bringing psychiatry more effectively into the community I have directed recently that in the capital building programme greater emphasis be placed on the provision of short-stay psychiatric units in general hospitals, staffed by specially qualified nurses which was one of the principal recommendations of the Commission on Mental Illness. Some such units have already been provided and I am happy to say that no less than 15 such units are now included in the building programme.
Health education can play an important role in helping to stem the flow of patients into the huge psychiatric hospital complexes which were built up during the past century. The preventive section of the report of the Commission on Mental Illness will be receiving priority attention from now on.
I am glad to be able to report further progress in the adoption of measures for combating drug abuse. The preparation of legislation which will strengthen and improve the existing controls and enable heavier penalties to be applied for offences involving illicit traffic in drugs is now well advanced and I expect to be in a position to introduce the Bill very shortly.
However, I am sure that Deputies will be aware that the enactment of up-to-date laws and their enforcement is only one facet of dealing with the drug problem. In my last Estimates speech I gave details of the steps which have been taken by my Department in initiating and developing a programme of education and publicity on drugs and the provision of treatment facilities for persons dependent on drugs. But others have also a part to play in this—such as other Government departments, voluntary organisations and responsible members of the community.
The ideal situation would be to have a fully integrated and co-ordinated programme based on a multi-disciplinary approach to the problem. Since drug abuse, in the sense that we have come to understand the term, is a comparatively new phenomenon, it is doubtful whether any country in the world can claim to have attained that goal. In this country we are fortunate that the problem so far has remained manageable. This is all the more reason why a concerted approach is now needed, and as a step in this direction, I have invited a number of Government Departments and other bodies to nominate representatives to serve on a co-ordinating committee to keep the position under constant review. The setting up of such a group is in line with the recommendations contained in the report of the working party on drug abuse, which stressed the need for close and continuing liaison between the interests concerned so as to ensure, through exchange of relevant information, that the problem is being effectively dealt with.
The National Drugs Advisory Board have for a number of years been operating a monitoring scheme to determine the safety of new drugs.
I have taken initial steps with a view to establishing a system of registration of pharmaceutical manufacturers and their products which would be based on inspections of plants, processes, etc., carried out by a suitably qualified and trained inspector. This scheme should enable this country to comply readily with the requirements of the EEC directives as well as the EFTA Convention for the mutual recognition of pharmaceutical plant inspections.
Following on the recommendations of the Study Group which examined the Child Health Services, revised procedures were introduced in October, 1970. A plan was then drawn up in my Department to implement the recommendations of the Study Group and to offer to all children, by 1975, a detailed child health examination at ages six months, one year and two years.
To date, the six-month examination has been successfully introduced in all health board areas and in almost all towns with populations of 5,000 and more. The examination at 12 months of age has also been introduced and is in operation in many towns. It is part of the plan gradually to extend the detailed pre-school health examination service at the ages indicated and to make it available to all children in all parts of the country. A high rate of parent response has followed the inauguration of the six months examination.
The revised school health examination service is now in operation in most counties. This service provides for a comprehensive initial examination of all school entrants, with the selected examination of children in the age group 9-10 years.
A number of the doctors providing pre-school examinations have attended training courses abroad, and many others have attended courses organised by the Society of Medical Officers of Health in Dublin and Cork.
In their report presented just more than four years ago, the Study Group on the Child Health Services drew attention to the late age at which children suffering from deafness were being referred for expert assessment and treatment. Steps have been taken to train nursing staff so that assessment of deafness can be speeded up.
In my previous Estimates speech I referred to the introduction of the Rubella (German Measles) Vaccination Scheme under which 12 and 13-year-old girls will be protected against this disease, which, if contracted during the early months of pregnancy, can give rise to a very real possibility of serious congenital defects in the baby. Such returns as are to hand for the year 1971, the first year of its operation, show that there was a most gratifying response, averaging around 75 per cent, to the scheme, thanks to the dedicated work of the C.M.O's and their staff.
The working group which, with the agreement and co-operation of the profession, I set up in May, 1971, to survey the workload of public health nurses is at present preparing, for computerisation, the returns completed by the nurses during the survey period which began on the 16th February, 1972, and ended on the 15th March.
The Group expect to be in a position to present their report to me before the end of this year. From this I will evaluate gaps that may exist in the structural organisation.
Increasing attention is being given to the social services aspect of community health care, with the appointment of a programme manager to health boards who will have special responsibility for co-ordinating the non-institutional services and with stimulating greater awareness among the public generally of the need for organised voluntary service.
There have been a number of specific developments of importance recently to which I should like to refer.
First, I have asked all health boards to consider arrangements for the introduction of a home help service in their areas with the object of helping people to stay in their own homes who might otherwise have to be maintained in hospitals or other institutions.
In its initial stages this service will inevitably be on a restricted scale as there are many problems of organisation involved, apart from the financial limits within which it must operate. The aim will be to build up gradually a system which is suited to our own social and economic circumstances. Care must be taken, for example, not to discourage traditional patterns of assistance by families or neighbours.
I believe that this is a service which should ideally be operated through the agency of established social service organisations engaged in co-ordinating social work activities. Only in exceptional circumstances will health boards be involved in the direct provision of home help. The prospects for development of the service in each area will, therefore, depend to a large extent on the willingness and capacity of local voluntary organisations to organise and run it.
The home help service will give a big boost to local schemes for care of the aged. The activities of social service councils and similar organisations on behalf of old people will be encouraged further this year by the allocation of £100,000 over what was spent by health boards last year in grants to these bodies. I believe that the best value, in social and economic terms, from these extra funds will be got by channelling them through local social service councils rather than by having them paid direct to individual voluntary bodies. I think that a true community spirit can best flourish where there is co-operation and consultation between people who are performing similar services in a particular district. I should like to emphasise that I am far from wishing to see individual societies and other bodies who have long been active in the social field lose their own identities or abandon their traditions. On the contrary, the individual slants of its constituent bodies are essential for a social service council which is to be rounded in outlook and lively in action. But what I want to avoid is overlapping and waste in a field where there is so much to be done and where it is essential that the valuable human resources available are concentrated to the best advantage.
I am glad to tell the House that the three social worker advisors appointed to encourage the development of social service councils have reported that 16 social service councils have been formed in the last two years.
At national level, the development of the social service council idea and encouragement of voluntary effort generally are being forwarded by the National Social Service Council, a body which represents a good cross-section of voluntary and statutory interests in social work activity. This national council now has the services of a full-time director.
In general, therefore, I think we can report progress in the field of community services.
I regard the establishment of social service councils as my number one priority in the development of our Health Services.
The Estimate includes the sum of £90,000 for health information and education, which is £20,000 more than last year. I intend to continue the Department's anti-smoking campaign on television, to provide reliable and balanced information and advice on drug abuse and alcoholism by means of further seminars for school teachers, informative pamphlets, talks by experts in these subjects, and by making one or two films on drug abuse and alcoholism, if this is found to be necessary.
Newspaper advertisements will continue to be used as appropriate—for instance, Deputies may have seen the Department's recent advertisements on coronary heart disease which mentioned that over 600 people under 55 years of age die each year from coronary heart disease, the vast majority of whom are in the age group 35-54 years. The premature deaths of men and women in the prime of life, often leaving young families behind them, is most unfortunate. We all know of such cases.
The strains and stresses of modern life probably give rise to many of the premature deaths from coronary heart disease and I would like to take this opportunity of drawing attention to some of the means of preventing such premature deaths, that is (1) stop smoking cigarettes, (2) keep an eye on your weight; eat and drink in moderation, (3) take reasonable exercise regularly and (4) keep in touch with your family doctor about your health.
Much publicity has been given in recent weeks to teenage drinking and allegations have been made that many publicans serve drink to boys and girls under 18 years of age, which is illegal. Enforcement of the law governing the sale of alcoholic drinks is a matter for the Minister for Justice and the Garda, not for me, but as Minister for Health I am naturally concerned that if young people drink too much and too frequently they may become dependent on alcohol, which can be very upsetting for their own lives and for their families, whether this be their parents or their wives and children. Some may become alcoholics, and alcoholism is a serious social problem in this country—and in other countries, also, of course.
Proper upbringing of children by parents and school teachers is of fundamental importance in combating alcoholism and drug abuse. For instance, psychiatrists point out that a person of stable personality is unlikely to become dependent on drugs, but the development of a stable personality depends on the love, understanding and encouragement given to the young person, particularly by his or her parents. This is something of which we all need to be reminded from time to time.
Another aspect of the rearing of children is providing them with proper foodstuffs and correct diets. I have heard it said—and I do not doubt this —that many mothers do not feed their children properly because they give them the wrong things to eat, not always because of lack of money but due to mistaken ideas or habits. To help mothers of families in this field I intend to have published during the coming year an informative pamphlet on nutrition and balanced diets. This pamphlet will be available free of charge and I hope to get the widest possible distribution for it into households, schools, colleges, et cetera. I also intend to use television publicity in this field.
In February, 1972, I introduced regulations to control the use of preservatives, antioxidants, colouring agents and mineral hydrocarbons in food, and the presence of arsenic and lead contamination in food. These regulations are based mainly on the recommendations of the Food Advisory Committee and they are part of a programme to up-date our controls in this field. The committee are at present examining at my request whether similar controls should be adopted on emulsifiers, stabilisers and solvents in food.
In connection with the entry of Ireland into the European Economic Community my Department have a major interest in the Community provisions relating to the medical and para-medical professions, the pharmaceutical and allied trades, food additives, and certain aspects of social security. Officials of my Department have been participating in the negotiations on adaptation of the existing Community legislation to suit the enlarged Community and have succeeded in having agreement reached on transition arrangements to suit Irish interests where this was considered necessary. Proposed directives in relation to health matters are being examined in my Department in co-operation with the appropriate interests concerned.
As I have said, there has been a wide circulation of information on the health services. I think it advisable to set out for Deputies in abbreviated form the basic structure of national health policy:
1. The reorganisation and co-ordination of the hospital system, taking account of growing specialisation and the need for teamwork, serviced by up-to-date equipment. The Medico-Social Research Board's information service will provide data where it is not already available.
2. The continued improvement of hospital accommodation and equipment. The development of further out-patient clinics wherever required together with hostels for patients under observation, attached to general hospitals. The construction of two general hospitals, at St. James's Hospital and the James Connolly Memorial Hospital. The construction of the Cork Regional Hospital. The continual planning for general hospitals for the country at large. The development of more efficient hospital management through management and work study investigations and through the appointment of programme managers for each health board who can work with hospital management committees where required.
3. The development of geriatric services, including assessment, rehabilitation and institutional care, with the emphasis on domiciliary care by staffs of health boards and by voluntary organisations. Home helps can now be financed with a contribution from State funds. The contribution to voluntary work for the care of the aged has been increased.
4. The development on a voluntary basis of social service councils, aided by State and local finances, in order to provide a great range of voluntary services for old and young. Co-ordination between these councils and the statutory authorities through their programme managers, social workers, home assistance officers, doctors, public health nurses and other medical staff.
5. The on-going development of the child health service to cover all areas of the country. The extension of paediatric out-patient clinics where required.
6. The development of some 15 short-stay psychiatric units at general hospitals, manned by specially qualified staff. The development of out-patient decentralised psychiatric services, and day hostels. Continued efforts to encourage the recruitment of psychiatrists and psychiatric social workers. The provision of industrial therapy units where required. The commencement of a mental health programme on an extensive scale. Improvement of mental hospitals.
7. The assessment of the alcoholism scourge and appropriate means to secure the attention of the public to the need for a new approach to excessive drinking. This will be effected by a survey being undertaken by the Irish National Council on Alcoholism. The appointment of social workers to health boards, with the sole duty of combating alcoholism. The continuation of the campaign to combat drug abuse with particular stress on education for teachers, parents, and other organisations.
8. The provision of 1,200 more places for mentally handicapped persons, including adults. The reconsideration of the present assessment methods, rehabilitation and training schemes in the light of experience. The development of day centres.
9. The examination of the report by the commission on general practice, when prepared.
10. Consideration of the means by which to establish a college of nursing. The improvement of nursing staff accommodation and continual review of nursing duties and staff structures. The particular application of work study in relation to nursing duties.
11. The massive development of health education, using all the media of communication.
All these policies are in gradual process of implementation. Of these policies I regard the development of community voluntary services as the most important. May I repeat again the necessity of adopting the management proposals suggested to the health boards.
The national policy being defined, each health board will be informed annually of the volume increase in current expenditure and capital available from various sources.
The health boards should receive from the CEOs a performance, efficiency and financial report on the health and hospital services in the area. The health boards should receive from the CEOs a list of improvements in the services and capital construction proposals. The boards can direct the CEOs in the preparation of these reports and make such amendments as they wish. The health boards can then choose the priorities for the coming financial year.
The health boards will have the assistance of the regional hospital boards in regard to hospital budgeting, in which the voluntary hospitals will be included. They will examine proposals for reorganisation or co-ordination of hospital services. Comhairle na nOspidéal will have the final decision where proposals for the appointment of consultant staff are concerned. The county advisory committees will present to the health boards reports on aspects of health and hospital services that they regard as important.
This system ensures a wide understanding of the health administration in any area with communication down to county electoral area level, and enables steady progress to be achieved.
The health boards will be at full performance level when, with fully recruited staff, they are able to benefit by this system of assessment, criticism, advice from the advisory committees and the planning and implementation procedures.
I now turn to the motion before the House for the approval of the draft of the Health (Hospital Bodies) Regulations. The explanatory memorandum which I have circulated with the draft sets out the legal background to these regulations: they arise from the enactment of section 41 of the Health Act, 1970, which provided for the establishment of four bodies for the co-ordination and development of the hospital services.
It must be recognised that the health boards could not, on their own, achieve full co-ordination of the hospital services, for two reasons. The first was that the pattern of the eight health board areas does not allow sufficiently for the fact that the influence of the major hospital and teaching centres in Dublin, Cork and Galway extends beyond the areas of the health boards where they are situated. The second reason arises from the fact that about half of all the hospital beds in the country are in voluntary hospitals. Even if the health boards were otherwise suitable, they could not be regarded quite as the appropriate bodies to co-ordinate the activities of the voluntary hospitals and those of their own institutions: participation by the voluntary hospitals in this co-ordination was regarded as essential.
The health boards, of course, were established partly because a very large proportion of patients, mental and medical, were not admitted to hospitals within their county area. The regional hospital board concept is based on the same practical approach.
It has been a fundamental part of the thinking on the future development of the hospital services that the health boards will continue to operate their own hospitals and that the voluntary hospital authorities will retain control of theirs. In this respect, I would draw the attention of the House to my statement of 22nd July, 1971, Official Report, columns 2363 to 2365. We are indebted to the voluntary hospitals for the services which they have rendered in the past and we are confident that they will continue to play an essential part in our health services. I think, however, that it is fair to say that all concerned, including the voluntary hospitals, recognise that in a modern hospital system separate units cannot be given the resources to act in isolation.
The hospital system is outstandingly the most costly element in the health services, representing about two-thirds of total public expenditure on the services. Because of a combination of technological advances and the improvement of pay and conditions in what is a labour-intensive activity hospital costs are advancing rapidly and at a rate exceeding the general advance in costs in the economy. For the current year the estimated total cost of operating our hospitals comes to about £60 million and this is an increase of about £6 million on the figure for the last financial year.
This calls for special steps to ensure two desiderata. The first is that the desirable advances in medical specialisation will proceed in a rational way so that our hospital patients will have the benefit of the new developments in medicine without involving the community in excessive outlay through uncontrolled, overlapping and wasteful development. The second is that through the development of hospital services on a unified basis and the application of modern management techniques a more effective and efficient hospital service will be achieved.
It is recognition of these facts that gives rise to the proposals in the draft regulations before the House. They are, in brief, designed to provide administrative machinery, involving participation by the main interests concerned, which is designed to see that the enormous resources going into our hospital system are fairly and effectively allocated.
Section 41 of the 1970 Act provides for a national body—Comhairle na nOspidéal—and three regional bodies based on Dublin, Cork and Galway. The functions of Comhairle na nOspidéal are such that it will be involved in decisions at the national level on priorities in the main lines of development of the hospital services. Its influence will arise particularly from the fact that it will decide on where new consultancies of various kinds should be created in hospitals and on advising the Minister on general policy on hospital development. It is my intention that the comhairle will be a prestigious body and I intend to see that it will be given such facilities as are necessary for it to do its work effectively. This means that it must have facilities, such as are now available in my Department, to do full statistical analyses in relation to the hospital services and their future needs. The membership of the comhairle will include a representative number of consultants and other persons concerned in the operation of the services. From preliminary thinking on its constitution, I am satisfied that there will be no difficulty in having a membership of very highly qualified personnel.
With the general pattern evolved through the comhairle, each of the three regional hospital boards will have the task of co-ordinating the activities of the different agencies involved in the hospital services in its region. Hence, these boards will be charged with co-ordinating the activities in this field of the health boards and the voluntary hospitals. Article 8 of the draft regulations itemises the functions which the regional hospital boards will perform for this purpose. Among the functions listed is the examination of proposals for extending or changing the use of a hospital or for discontinuing a hospital. This will, of course, be a very important part of the work of the regional hospital boards. The boards will be expected to take cognisance of local views before reaching decisions and, indeed, it is provided that the views of the local committee set up under section 7 of the 1970 Act must be sought where the issue is one of discontinuance or change of user. No major decision affecting a hospital in this respect will be made without regard to the local views thus expressed.
These boards will also play an important role in the examination of the budgets of hospitals and in allocating financial resources. They will be the source of advice to hospital managements and will have authority to organise services, such as work study, to improve management and efficiency in hospitals.
The Dublin Regional Hospital Board will cover the areas of the four health boards on the eastern side of the country; the Cork Regional Hospital Board will cover the areas of the Southern and Mid-Western Health Boards, and the Galway Regional Hospital Board activities will extend to the areas of the Western and North-Western Health Boards. In accordance with the Act, half of the membership of each of the regional hospital boards will be appointed by the health boards and the provisions in the regulations are such that each health board will nominate four members to a regional hospital board. The other members of the regional hospital board will be appointed by me. It is my aim that the boards should be broadly representative of the various interests in the region, including the voluntary hospitals, and I think that it is essential for my Department to be represented on the boards.
Before putting the draft regulations into final form, I had widespread consultations with the interests which will be affected by them. The proposals for the regulations were referred to the National Health Council, the health boards, each voluntary hospital, the medical teaching bodies and the bodies representing the medical and related professions. Wide-ranging views were expressed on the proposals and, in preparing the final draft, I took all the views expressed fully into account. Some views I was able to meet and, where I could not accept suggestions, I have explained the reasons for this to the interests involved who, I think, generally acknowledged that, in an exercise such as this, it is not possible to meet fully the viewpoints of all interests. I do not think it necessary for me to recite to the House all the detailed views expressed on the draft, but I would like to refer to a few major points which did arise.
Some health boards questioned the timing for the establishment of these bodies and suggested that the proposed regulations be deferred for some years, until the new administration under the health boards had settled down. The Eastern Health Board also suggested that the administration of the Dublin Regional Hospital Board should be tied in with that for the health board. As regards the timing of the establishment of the new bodies, I do not think it would be wise to wait. To do so would leave a hiatus, as it would be difficult to maintain adequate continuing machinery for co-ordination between the hospitals of the health boards and those of the voluntary bodies. Neither could I accept the proposition that the health board personnel should also act to provide the administration for the regional hospital boards. In my view, it will probably be better that the personnel administering the regional hospital boards and Comhairle na nOspideál, should be seen to be independent of both the health boards and the voluntary hospitals, but, of course, acting in close association with them.
A point on which strong and conflicting views were expressed was the future arrangements for the selection and appointment of hospital consultants. It is important here to make a clear distinction between selection and appointment. I have explained on a number of occasions that, while the Act provides for Comhairle na nOspideál being given selection functions in due course, these can be given only by further regulations, made after the comhairle itself has been set up and has been consulted, after bodies engaged in medical education have been consulted, and after a draft has been approved by both Houses of the Oireachtas in accordance with the procedure which is now being operated for the current draft regulations.
Accordingly, I have made it clear that there is no immediate issue of a change in the selection procedure for consultants. However, the last and final phase of health and hospital service reorganisation, namely, that Comhairle na nOspidéal will be charged with the function of establishing a procedure under which all consultants, whether in health board or voluntary hospitals, will be selected through the same machinery, will be pursued with alacrity. Consultations for the regulations to set up the necessary procedures for this common method of selection will be undertaken just as soon as Comhairle na nOspidéal is fully functioning.
On the related but distinct issue of the appointment, or engagement, of consultants, the FitzGerald Report had recommended that all consultants would hold their contracts from the regional hospital boards. Provision in relation to this was included in section 41 of the 1970 Act. I then put out, for discussion with all the interests concerned, proposals whereby all consultants would operate under a common form of contract which they would hold with the regional hospital board and would be assignable, as required, to different hospitals within the region. The advantages of this would lie in having greater flexibility in the organisation of consultants' services.
This proposal, in its entirety, did not commend itself to all the interests consulted. In particular, the hospital authorities—and notably the Dublin voluntary hospitals—pointed out that it would be more advantageous if the contract was between the consultant and the body managing the hospital. On the other hand, the medical organisations wished to retain the concept of the regional hospital board holding the contract, but were opposed to the concept of a consultant being transferable by the board from one hospital to another without his agreement.
Accordingly, I amended the draft and, as it now stands, the regional hospital board would only be involved in making a contract with a consultant if the hospital authority or authorities concerned agreed to this. In most cases, I would expect that contracts by the regional hospital board would apply where a consultant was needed to serve a number of hospitals under different managements. Otherwise, it seems likely that the authority employing the consultant will remain as at present, that is, it will be the health board or the voluntary hospital body concerned.
As far as the effectiveness of the services will be concerned, I do not think that this change which I have made will of itself be very significant. I would again stress that this does not mean that the aim of having a common selection process for all hospital consultants has been abandoned or deferred. Indeed, I would hope that this change will ease the way to general agreement on a common system of selection. I intend that any appointments of consultants by regional hospital boards will be based on this common selection system and it seems better to defer the exercise by these boards of this function until that system has been evolved and prescribed, rather than to have them introducing interim ad hoc selection methods.
Many views were expressed on the size and membership of the bodies. A number of those consulted suggested increasing the membership of Comhairle na nOspidéal and of the Cork and Galway Regional Hospital Boards. I have also had very many requests for representation on each of the bodies. Clearly, I could not accede to all these requests without having an unmanageable and ineffective membership of the bodies. Accordingly, I have not increased the membership of the bodies and realise that in choosing members I will have a difficult task in balancing the conflicting wishes of many of those who were consulted. I hope it will be taken by all that my final decision on this, when I take it, will be a reasonable one, taken in the interests of the services as a whole.
Before leaving the matter of the consultations on the draft regulations, I would like to express to the House my appreciation of the interest shown by all concerned in the proposals and of the time which was given by many people in health boards, voluntary hospitals and other organisations in preparing the views on the proposals.
As a consequence of the establishment of the new bodies, the Hospitals Commission will be dissolved under section 42 of the 1970 Act. The work for which the commission was designed will then be absorbed in that of the new bodies. The functioning of the new bodies will also affect the work of my Department. If clear-cut decisions are not taken on the exact division of work between the different organisations, there will be considerable scope for overlapping and ineffectiveness.
It is my aim that, as far as is practicable, we should clarify from the start the roles of the Department visa-vis the new bodies and that those bodies should have an administration suited to their requirements. To this end, I have arranged for Messrs. McKinsey, the firm of management consultants who reported in relation to the health boards, to make recommendations on the administrative procedures and the staffing of the new bodies. I expect that their report on this will be available as soon as the new bodies are ready to become functional.
The management consultants will also look at the relationship between the new bodies and my Department and the impact of their establishment on it. Clearly, if the comhairle and the regional hospital boards operate satisfactorily, this will result in the devolution of work from the Department, a devolution which, I might mention, is in accordance with the concepts in the Devlin Report on the reorganisation of the public service. I should stress that in evolving the detailed arrangements for the new bodies we will avoid duplication as between them and my Department. When detailed work in examining and co-ordinating proposals is devolved, it would be pointless and frustrating were the Department to duplicate this work by conducting its own detailed examination. Full participation by the Department in the new bodies will help to avoid such a situation.
The proposals to establish these bodies might be criticised as adding to the complexity of health administration. In reply to this argument, I would say that, given the existence, and the intention to continue the existence, of two parts in our hospital system, one under the health boards and one operated by voluntary bodies, some complexity in administration must be accepted, if we are to have proper co-ordination of the whole system, involving participation of those involved. The proposals might also be criticised on the grounds of administrative cost. I accept that there will be additional administrative cost but, in relation to the total cost of our hospital system, which, as I have mentioned, is at present running at about £60 million a year, the administration of the new bodies will not be significant. The costs of our hospital services have given rise to considerable public disquiet recently and, each year, the House has seen in the discussion on the Health Estimates the continuing steep rise in costs. I do not say that the establishment of the new administrative organs will stop hospital costs rising—no modern State could expect this if a reasonable level of service is to be provided—but I am confident that they will contribute very substantially towards making sure that resources are properly and knowingly allocated and that value is obtained for the large sums of money which we spend on the services.
The setting up of the health boards and the regional hospital boards, the county advisory health committees and Comhairle na nOspidéal, represent the ultimate in developing a specific national service by decentralisation of executive services, by ensuring maximum communication down to county electoral area level, while at the same time ensuring general national control at ministerial and Oireachtas level.
I think the Minister will be good enough to bear with me in the course of my address when he bears in mind the fact that the last few years under his benign influence have seen, perhaps, some of the most radical changes in the whole structure and application of health services and that during those years I found myself transferred from the responsibility which I once bore in these benches for health matters into the equally rapidly changing world of foreign affairs, not to talk of the calamitous and distressing situation in the North of Ireland. This did not permit me, I am sorry to say, in the last few years to apply myself as I would have wished to what I believe to be one of the most rewarding fields in which any public person may be called to serve, the field of health services. And when added to that problem I have the immediate task of trying to digest the Minister's very full and helpful speech he will realise that of necessity I shall hop from topic to topic and if I am not as well informed as he would wish me to be, I hope he will understand that, perhaps, I am no worse informed than many members of the general public who are equally busy about their necessary tasks and if I display ignorance in some matters it may be a reflection of the general ignorance which exists.
One of the most significant changes in the field of contribution towards health costs and benefits is in respect of people in the middle income group who have been required to pay, under the orders which were made last year, £7 per annum. The extraordinary thing is that the larger proportion of these people are still unaware of the benefits to which they have become entitled. This ignorance applies also to very many of the health administrators because from time to time— and I am sure I bear a burden which applies to other Deputies also—we are called upon to explain why, having paid £7 per year, people are asked to pay hospital bills. As I understand these regulations, they should not be required to pay hospital bills if they are paying the £7 per annum irrespective of income. If I am right in this understanding, I hope the Minister will take steps to advise all hospitals that demands of this nature should not be sent out. It may be through some breakdown in communication that the patients do not make known to the hospitals that they are in that particular bracket but it is rather distressing when people receive these bills and are worried by them.
I was also appalled in recent weeks to discover that children who had been examined in the course of school examinations—children aged six or seven—and referred to hospital for further examination had demands made on their parents for payment of examination fees of, I think, 25p at the hospitals. In some cases parents were aware that they were not under any obligation to make that contribution but in several cases that have come to my notice the parents were not so aware. That hospital authorities who are aware of the fact that these services should be given free should make these demands is utterly and completely deplorable. I will give the information to the Minister and name the hospital in question so that the matter can be corrected. I would hope that representations that have already been made will mean that further steps will not be required but, if further steps are required, then I am sure the Minister will take them.
I am at a loss to know why it is that parents attending with children for such examinations at hospitals in addition to being called upon to make these contributions—people who are unaware of the law and who are asked for a sum of 25p in relation to an examination will assume that it is a legal obligation and they will pay it—have also been asked to disclose the national health insurance number of the bread winner of the family. This, again, appears to be a totally irrelevant question. The service is either free or it is not and it should not be related to whether the child is a child of an insurance contributor.
These matters indicate that while a great deal is happening in the whole field of health much of it is still unknown to the general public. It underlines the criticism which has come from the Fine Gael benches for over 20 years, that our health services are unnecessarily difficult, that they have injected into them far too many means tests, far too many examinations as to means and circumstances, which are inefficient and costly in administration but are equally indefensible because they are degrading to the individual and at a time of ill health they add greatly to the burden of worry and, therefore, ultimately, to the prospect of rapid discovery.
They underline an admission which is contained in the Minister's speech today that we in Ireland are an exceedingly hospital-bed-ridden people. One of the greatest fallacies is that we are a priest-ridden people; that is the one one sees most frequently trotted out, particularly by instant commentators who come into our midst for 24 hours. That is totally and completely false as the Minister on many occasions, he being a member of a minority religion, has been only too glad to confirm. What is a truism and an appalling admission of the whole wrong basis of our health services is that we are a hospital-bed-ridden people. There are far more of our people per head of the population in hospital than in any other country in the world which compiles and presents statistics.
In speaking of this field I am discounting the large number of geriatric cases we have in relation to our population because of the fact that because of large-scale emigration over the years and other problems we had an unusually and undesirably high number of people confined to geriatric beds.
Of our total population of nearly 3,000,000 we make hospital accommodation freely available to 90 per cent but we make our home medical services freely available to only 30 per cent. I think the figure the Minister gives is that 65 per cent of the total health cost is related to institution— hospital—costs. This is certain to continue as long as we have a system so wrongly founded that it sucks in people from their homes into hospital beds. Is it not a totally idiotic system that maintains people, free of charge to themselves, but at expense to society of £100 a week, in a hospital bed, merely because we will not expend annually a sum in relation to our people of £5 per head to keep people out of hospitals and have them treated at home? As long as we maintain this idiotic system we will not make any worthwhile impact on our total health costs, McKinsey or Childers or all the health boards and authorities notwithstanding.
I know it is unfair to expect that any short time rationalisation of health services will make in the short term a really worthwhile impact in reducing health costs. It certainly will not as long as we maintain a system which is wrongly orientated. The only worthwhile change that can come about will be by a total rejection of the system which has operated up to now.
According to our assessment of the situation, 70 per cent of our total health costs are in respect of institutional care. In Britain the figure is only 62 per cent. The Minister, in his statement today, gave us figures showing how much higher the rate of entry to hospitals is in Ireland compared with Britain. He points out that the pattern of demand for acute hospital admission in Ireland is 119 people per 1,000 of the population. That is an extraordinarily high figure. Twelve per cent of the population in Ireland seek and are given every year acute hospital attention and in Britain the figure is 10 per cent. The Minister suggests that the reason why it is not higher in Britain is that Britain has a very large waiting list of persons seeking entry to hospitals which fortunately, in most cases, we do not have although it certainly applies in some sectors. That is not the full answer. Our whole system is wrongly orientated and is such that a doctor who is considerate of the interests of his patients will have the patients referred to hospital so that they can avoid the burden of paying for domiciliary medical care and for the drugs and medicines which is most cases these days are far in excess of the cost of paying fees to professional gentlemen for their treatment.
Now we have the new drug assistance scheme—the Deputy is aware of that?—£3 to £5, which is a very good contribution.
It can be of assistance where you have people who are suffering from long-term ailments like asthma and neuritis which require the constant use of drugs and medicine but, again, it is a scheme which requires so much paper work, and of which many people are still unaware. After a number of years they may become more aware of it. Many Deputies must have the same experience as I have that one regularly has people attending, seeking assistance to get medical cards and it is rare that any of them is aware of this new drug assistance scheme.
It only started in April.
I know it started in April. As a Dublin Deputy I have to deal with as many as ten or 15 medical card applications a week and I find it startling that people are not yet aware of the scheme. One finds that the process of proof of expenditure and the necessary medical certificates and prescriptions which have to be got is off-putting: people are discouraged from making applications even though the costs of processing the scheme must be away in excess of the 3.5 per cent given as the cost of administering some schemes. The cost of administering this scheme must be considerable.
I think the day is not too far distant when the Minister or some successor will be coming in here and seeking the abolition of even the £5 a month ceiling. I know this ceiling is applied as a brake, like the charge of 6s a day was for people in hospital. That charge was later increased to 10s and a point came ultimately when it was found the scheme was unwieldy, too costly, inefficient and that it imposed an obligation on people far beyond any saving to the Exchequer. The same will apply to the £5 per month ceiling in relation to the drugs scheme.
I find fault with the Minister's claim that the State is now subsidising the health services to a level of 70 per cent, because that claim rules out what the Department of Health persistently refuses to accept responsibility for: the cost of home assistance which in a growing number of areas is used to pay for medical facilities and which is multiplying home assistance expenditure and therefore the burden on the rates. For humanitarian reasons, local authorities realise the intrinsic human value of keeping people in their homes rather than sending them, because of lack of care in the home, into institutions. This has led to a situation in which the number of people seeking attention in geriatric hospitals has fallen, but this contribution is being made exclusively at the expense of the rates. Therefore, before any assessment is made of the State's contribution to the health services, it is only fair that this factor should be taken into account.
Of course, I suspect the Minister for Health is not personally responsible. Predecessors of the Minister and, I expect, the present Minister, have made representations to the Ministers for Finance, Social Welfare and Local Government in this matter, but it is very poor form that so many Ministers and organs of Government should be a party to the concealment of the assistance which is being given by the local authorities—that they should be a party to this fraud that is being perpetrated on the ratepayers by pretending that the State is giving more assistance to the rates in the matter of health charges than it is.
For many years it was the great concern of enlightened people that Ireland was the dump of the world for foods and other commodities which were rejected under legislation applicable in other countries in relation to poisons and additive matters in food. I know that in February of this year the Minister made regulations which to some extent control additives in foodstuffs but I should like to hear from him what active steps are being taken to enforce them. My information is that even since the regulations were issued foodstuffs condemned in Britain and, perhaps, elsewhere, as not complying with their standards have been exported from Britain and sold and consumed in Ireland.
Although the Minister has made a start to control food additives, we are still a long way from achieving the safeguards applicable in most European countries, including our prospective partners in the EEC. Those countries for many years had imposed more and more stringent controls on food additives, on insecticides and other such substances. In this matter we are dragging our feet too much. The Minister has appointed a number of councils but I suspect there is a wide range of regulations which the Minister could make without going into that unnecessarily lengthy and involved process. I would urge him to make minimum rules and if, later on, any tidying up is necessary as a result of advice from councils, that could easily be done.
There was some mirth in the House recently when a Deputy asked if there was any evidence of increasing rat infestation in Dublin. The Minister said there was no information to hand which would lead people to be alarmed. This is not the picture which I find reflected in what I have been told by people who come to me as a public representative. Indeed it appears as if there is a very alarming increase in rodent infestation. This may be partly due to the rate of house building, to the demolition of old structures. There has been a disturbance of the whole centre of the city and of old buildings. As well, there has been the ripping up of virgin areas and this may have upset the whole pattern of rodent life. It appears, at any rate, that there has been a vast increase in rodent infestation. Perhaps the use of the term "rodent" does not lead to such mirth as the word rat does, possibly because of its colloquial application to man, but I would urge that the matter be investigated very carefully and that such remedial action as is possible will be taken.
I have crossed swords with the Minister in the past in regard to detergents used by housewives in their home washings. I have urged, and the Minister has not accepted my plea, that all detergent packets should contain very specific warnings about dermatitis and other skin diseases arising from their use. I suggested that the packets should contain advice about the possible use of rubber gloves but in turn I have been advised by a number of dermatologists against the use of rubber gloves. This advice was given by people who in their professional lives have found that although their use by some people may not cause injury, some other people may suffer from their use.
We have had warnings published in one field of health hazard—the relationship of cigarette smoking and cancer. At the moment packets bearing a warning that cigarette smoking may be a health hazard are in existence. Now that we have taken that step, although belatedly, the Minister might see his way to give a warning in relation to detergents. We know that their use has become more and more hazardous. Hardly a week goes by without a boast by a detergent manufacturer that some new and more devastating ingredient has been put into the powder to dispose of dirt. I cannot imagine that there is not a serious risk involved. I would plead with the Minister not to wait for other countries to show themselves more active in this field. Ireland should be in the forefront of thinking in this regard so that housewives may be protected against these detergents.
In recent times cases have come to light of skin troubles arising from detergents. In many instances these diseases have been caused to people who have not handled the detergents, but have worn clothes washed in these products. This matter was referred to in some questions tabled today by my colleagues. Part of the Minister's problem in the past has been that officially not many cases were brought to the notice of the Department. As I explained on previous occasions, frequently this was because the people concerned consulted their legal advisers and found that there was no legal remedy in respect of damage to skin or any other part of the body arising from the use of detergents which are put on the market by manufacturers who take what is described as "reasonable precautions" to ensure their safety.
All that is necessary to show that reasonable precautions are taken to prove that the product is safe is to show that there is no statistical significance in the number of people who may be injured. Today I heard the Minister refer to the insignificance of some statistics but I am never persuaded by such a reference that there is not need for further research. Apparently a statistically significant figure has to be of calamitous proportions before it becomes apparent to health authorities that it is necessary to act. I hope our Department of Health will not rely completely on statistics which may not appear statistically significant, but which are vitally important when someone suffers a serious illness or is killed as a consequence of the failure of society to take the necessary steps to protect people.
There is reason to be concerned about the rigidity of regulations governing the inclusion or exclusion of doctors in the choice of doctor scheme. In the Dublin area it has meant that some doctors who had been conducting good practices for a short period found themselves, on introduction of the scheme, to be unacceptable because they did not have the necessary number of years in practice in a particular area. I hope that as the scheme develops there will be some relaxation of this code.
A number of cases have been brought to my notice of people who were eligible for free medical attention under the choice of doctor scheme but who had difficulty in having doctors assigned to them. I am aware that in some of the cases the families in question were what might be called socially difficult. They were known to be trouble-makers in their communities or perhaps were regarded as hypochondriacs. When the choice of doctor scheme was introduced any doctor who knew of the people concerned was only too anxious to push them on to someone else, with the result that, for some time, certain people have not been able to get the service promised in the scheme.
I realise that the scheme is in its early stages and, no doubt, it can be adjusted in the course of time. I understand it is open to a health board and, ultimately, the Minister to assign a particular doctor to such cases, even if the doctor is unwilling to undertake the work voluntarily. It is important that difficulties of this kind are ironed out because whatever social disagreement or dislike there might be in relation to such people it should be remembered that they may need medical care more urgently than people socially more advantaged.
Recent incidents elsewhere have drawn our attention to the need to take more efficient precautions against fire hazards in hospitals. Some years ago I inspected a geriatric hospital in the Dublin region and I found a ward of 30 beds where all the patients were bedridden. The fire escape from that ward consisted of two wooden doors. The outer door led to an iron staircase and the inner door led to a small porch from which one gained access to the outer door. To my amazement, I discovered that there was a bed of a geriatric patient placed across the inner door and I was even more appalled to find that both the inner and outer doors had been boarded up. When I inquired the reason I was told it was to keep out the draught.
That such a situation could arise in a Dublin hospital clearly indicates the carelessness of hospital authorities and of the community in general. It is vital that our carelessness in this regard is corrected. On many occasions I have urged the Minister for Education to introduce obligatory fire drill in schools, but the Department was not willing to do this. Fire drill in schools would have the advantage of making the schools more safe; in addition it would ensure that the children would be made aware of the risk of fire hazards and would be trained how to behave in the event of fire both in the event of fire both in childhood and adult life.
In the hospital to which I have referred, I am glad to say that when I complained about the matter the boarding was taken from the doors and modern patented draught excluders were applied to the doors; equally, I am glad to say that the bed was removed from near the inner door. The hospital now has a fire officer and this is to be welcomed. However, there are still areas in the country where proper attention is not paid to such matters. I would urge the Minister to ensure that steps are taken by way of a severe warning to hospital authorities, and particularly to the new boards, to see that first priority is given to this important matter. We do not want a situation in which we wait for a major incident, for a tragedy to occur before we take the necessary steps. In most cases it does not cost a great deal to provide minimum safeguards to ensure safety. This should be done, even in old buildings. It is not sufficient to say that the life-span of a building is short and that when the new building is erected that these matters will be attended to. Old buildings are more fire-prone than are new ones. The hospital to which I have referred was a very old one. It was a dreadful state of affairs that people should have been so careless as to create a real risk of a major tragedy.
The Minister has outlined what he considers are his priorities in relation to the health services. We find it difficult to fault them, although they might have been rearranged. One might think that one particular aspect was more important than another, but it would be churlish to fault the Minister generally in relation to his outlook. As the first priority we would prefer a total reorientation of the service so that we would have a free domiciliary medical service but, accepting that the Minister cannot see his way at present to do that, we would accept that his general order of priorities is not very wrong.
The vital statistics that the Minister has given us show a reduction in the rate of deaths from heart disease during the past five years that gives us reason to be hopeful. I would like to hear from the Minister the reasons why it is believed this reduction has been effected. In his speech I know that the Minister gives advice on how to avoid coronaries. These include controlling one's weight and taking plenty of exercise. However, I have been surprised in recent times to observe a number of people who complied with such advice and who did not smoke but who suffered from coronary difficulties. The age limit mentioned by the Minister, 35 to 50, seems to be the most vulnerable one but there are many cases on record of people who complied with all the advice given to them in this field but who, nevertheless, succumbed. I would like some indication as to what other factors are considered to be contributory to coronary diseases. The Minister has mentioned the general pressure of modern life. If this is a factor what are we to do to reduce that pressure? It is having its effect in relation to heart conditions and also in relation to mental diseases. It is a major field of medical social work in which, perhaps, we ought to be making a more significant investment than we are both in terms of money and resources. Unfortunately, there is a continuing increase in the number of deaths from cancer. We are only too willing to give the Minister the extra money he seeks in relation to the field of health education because any money spent on informing people in matters of health is money spent well.
In his figures for the health services the Minister mentions as one of the causes of increases in estimated expenditure in the current year compared with last year, a rise of £500,000 in general medical services to cover increased costs over 1971-72 in respect of the choice of doctor scheme and assistance towards the cost of drugs for patients in the middle income bracket. This is a very low figure in respect of a major advance in domiciliary and medical care.
That figure is the understatement of the year.
That is the figure we have been given. In another part of his speech the Minister complains of what he considers are possible misuses of the new choice of doctor scheme. We assume that this figure was assessed carefully and I would accept the Minister's assessment for this purpose: to show how small an increase, an increase of one-twentieth of the total domiciliary medical care, can produce this immense social advance of choice of doctor and also of providing assistance.
In the rest of the country the scheme begins only in October next.
Are we to understand, then, that the Minister has not taken into account the rest of the country?
In all but the Eastern Health Board the choice of doctor scheme begins only on October 1st.
We will accept that but within the present eastern health region there is probably more than half of the entire population of the country. Accepting that, we find an increase of only a half million which in a budget of almost £90 million seems to us to be proof of the validity of what we have been saying: that is, that the area in which to confer most benefit on the people is in the field of medical services outside of hospitals.
I know that the Minister is urging all health boards to give greater attention under the scheme of home help. I would ask him to use his good offices with the Minister for Social Welfare, who needs to be made aware of the desire of the Department of Health to get health authorities and society in general to give greater care and attention to people outside of hospital.
Within the past week I had brought to my notice the case of a CIE pensioner. This man has an invalid wife who requires constant attention. She is unable to clothe herself and cannot walk so that she must be wheeled about in a chair. In other words, she is dependent totally on the attention of her husband. This lady, with the assistance of some savings and presents from her family, was given an opportunity of visiting her children in England. The husband is 67 years of age and he is required to present himself at the labour exchange once a week in order to qualify for unemployment assistance; but because he absented himself for a fortnight to attend on his unfortunate invalid wife in England, he was disqualified from receiving his unemployment benefit during the period of his absence. I know that this is not strictly within the ambit of the Department of Health but the Minister will appreciate the detailed way in which the Departments of Health and Social Welfare dovetail with one another and it is very important that, if one Department are encouraging people to adopt a new philosophy and social approach, the Department of Social Welfare would not, by niggardly practices, be defeating the very advances in social medicine which the Minister would wish to encourage. Much greater liaison is required between the Departments of Health and Social Welfare.
I find that there is a great deal of jargon coming from the Department of Health and from the Minister himself generally which often I find frustrating because sometimes one can read a page of this jargon and find that the real thought could be condensed into one sentence. For instance, I find the Minister today talking about "forward planning". I could not imagine any planning except planning of a forward nature. Also, he uses other phraseology which indicates that the Department in their entire outlook are now drowned in the McKinsey Report. I am horrified at the dependence of the Department of Health and, through the Department, the health boards, on the McKinsey Report. When we saw a copy of the report first in the Eastern Health Board I forecast that we would be creating a top-heavy system of health administration. From what the Minister has said today and from what I have seen during the past two years I am not encouraged into believing that my forecast is not proving correct. The Minister tries to dismiss this criticism by saying that the new structure, the injection of new personnel and the promotion of others, has not imposed anything more than a ½p increase on the rates.
An increase of a halfpenny in the rates means that on the individual taxpayer it is an increase of over one new penny per £. I am not concerned with rates only. After all, if it is a halfpenny on the rates, if it is a half new penny on the rates, it is over a half new penny on the Minister's figure on general taxation. That works out at something like three old pence and there is a general readiness to dismiss figures these days when expressed in new pence. That is quite a considerable burden, I believe, and we have not yet seen any return from this restructuring commensurate with the additional financial burden which has been imposed.
In the list of new hospitals and new hospital works which the Minister has given us, both in respect of work completed to May, 1971, and work which will be carried through until May, 1973, which may be planned for later, I am sorry to see that we have not yet got an indication from the Department of Health of a readiness to provide the money to replace Hospital 3 in St. James's Hospital. Hospital 3 is a disgrace. That is the mildest way of describing it. That such a building should be retained in 1972 to house old people who are bedridden or who, if they are not bedridden, are little more than vegetables, is a blot on our society.
The Eastern Health Board and their predecessor the Dublin Health Authority have been endeavouring for 18 years or more, I believe, to get assistance towards the cost of the demolition of Hospital 3 and its replacement with a modern hospital. All their efforts in this regard have been thwarted by the Department of Health. I do not know whether the Minister is familiar with Hospital 3. If he is not, I urge him to go and inspect it at the earliest opportunity.
Apart from its appalling appearance and its vast workhouse-like wards with a totally depressing atmosphere, the sanitary equipment in it is misdescribed because it is insanitary. Bowls and pipes are broken and we are told that they cannot be replaced because, if any effort were made to replace some of the equipment, no successful connection could be made with the remainder of the piping equipment there, and the whole building would have to be gutted and all the sanitary equipment would have to be gutted.
Is it not an appalling situation that we have a building which is so decrepit, and all the essential facilities are so decrepit, that you cannot even make minor repairs without setting off a chain reaction of vast repairs which the Department are not prepared to undertake? This is unfair to the unfortunate people who find themselves there. It is a cause of very serious distress to their relatives who go to visit them. It is also a serious disincentive to staff who work under such conditions. The fact that the Eastern Health Board are able to maintain staff there in that building, even below the complement which is required, is a tribute to the staff, who are so devoted to those elderly people in a field which is not terribly rewarding in the human sphere because, in many cases, they are unable to get the response from these elderly people which is available to those engaged in more acute nursing.
I would urge upon the Minister to treat as a priority requirement the replacement of Hospital 3 in St. James's Hospital. I believe this is the least we can do for the elderly people in the Dublin region, and it is the least that we owe to the people who have devoted themselves over the years to nursing them and giving them medical assistance under impossible conditions.
I should like now to come to the new health hospital boards' regulations in draft. It is putting it mildly to say that this is a very delicate field because there are so many conflicting loyalties in the sphere of hospital consultancy. To say there are conflicting loyalties is not to denigrate them. We have every reason to be grateful to all the hospital authorities, both voluntary and public, and to the consultants who have worked in them and who have, in most cases, rendered medical assistance and care to the sick far beyond the call of duty. It is, however, a very delicate sphere when one endeavours to match the requirements of modern medicine and the difficulties of financing those requirements with old loyalties and old traditions. We accept that the Minister has no easy task in endeavouring to draft regulations or procedures to govern this particularly sensitive sphere.
It would appear that the policy of the Irish Medical Association in respect to consultant hospital appointments favours a more uniform system than that which has hitherto existed, some kind of a system which would give uniformity in the voluntary and nonvoluntary institutions. There is a great deal to be said for the argument that this is better done by agreement than by regulations that are imposed on the people involved against their will. I do not pretend to know all the problems, particularly outside the Dublin region, but I have some understanding, I hope, of the Dublin system.
The voluntary hospitals in Dublin have special arrangements with the three medical schools whereby the authorities in the medical schools sit in at the making of appointments. Clearly this is something which must be preserved. Indeed, it is preserved in Britain and elsewhere where there has been a standardisation of the whole hospital system. In the future, any system must give recognition to this very legitimate interest. We have the federated hospitals, the Meath, Mercer's, Sir Patrick Dun's, Steevens' Hospital, and so on, associated with Dublin University. We have St. Vincent's Hospital and the Mater associated with University College. The Richmond Hospital has a special association with the College of Surgeons.
The three maternity hospitals appoint their own masters. They are appointed usually from within the existing staff of the hospital. Without in any way belittling the contribution which has been made by all these hospitals in the past, I think that at this time of national conscience examination we ought to look at what is undoubtedly a sectarian structure in some of these hospitals. I do not use the word "sectarian" in any offensive way. These people are heirs to their own traditions and it is very proper indeed, and particularly in the very personal sphere of health and serious ill-health, that people should have close and immediate contact with the spiritual advice and spiritual background of their own choice.
It would be desirable, nationally as well as medically, if we were to help to break down the divides that have existed in the past in the hospital institutional structure. I would accept that the general objective of the new hospital boards will assist in this worthwhile programme. There have been criticisms, legitimate and otherwise, of the system of appointment of consultants in the past. I think we have done remarkably well in the consultants who have come to our people through a system which, I suppose, could be faulted if one were to look purely at administrative matters. Anything which can be done to retain the goodwill and the skills of the consultants who have come out of the system in the past is to be desired. I would hope, therefore, that it will be possible to negotiate a system which will be acceptable to consultants in both the voluntary and the public hospital spheres.
I should like to offer some particular criticisms of some of the Minister's proposals. The Minister says that, while the statute enables him to give powers to the new Comhairle na nOspidéal in regard to the selection of consultants for appointment, he does not propose to give those powers at this stage. I can accept the Minister's view that it would be desirable to have consultations with the new comhairle, after it gets to work and sees the full picture, and we expect that the Minister will be coming back here later on to get approval for a draft he may prepare in this field. As I say, I accept the Minister's view that it is desirable the comhairle should get to work at an early date.
I do not accept the view uttered by some of my colleagues in favour of postponing these new hospital authorities. If one is making a change, then the quicker the change is made the better in order to get everything working. That is one way of ensuring that new organisations do not become so entrenched in their own high regard that they will object to any future change. I urge the Minister not to delay too long in giving the comhairle any functions necessary in relation to appointments. I believe it will be necessary to give such powers; even if some harmonious arrangement is worked out with the Irish Medical Association, the consultants and the public authorities, they will still need the supervision of Comhairle na nOspidéal.
The Minister told us that, in accordance with the Act, 12 of the 23 members of the comhairle will be consultants. We regard this as correct and proper. These are the people best in a position to judge the skills of applicants for appointment and also to advise on the manner in which the comhairle should discharge its other functions in relation to hospital services. The Minister also told us that, in addition to the 12 consultants, it is proposed to appoint members of health boards, voluntary hospitals and officers of his Department. I would like the Minister to spell out the proportion. Will it be 4:4:3 or what will it be? It is important that we should know this.
I am disappointed that the Minister proposes to retain unto himself the power of appointing the chairman and vice-chairman. We had this out when we were debating the Health Act. I thought at that time that the Minister accepted that it was wrong for him to impose his dictates in this sphere and I am disappointed to find he has now, as it were, gone back to the bad practice of insisting that the Minister will select the chairman and vice-chairman. Why is the Minister not willing to leave this to the hospital consultants, the members of the health boards and the voluntary hospitals? Is he afraid these people would not appoint officers of his own Department? If officers of his Department are to be chairman and vice-chairman, then they should get these positions on their own merits. I would urge upon the Minister not to include in the draft regulations such an undemocratic provision, a provision which would deny to this council and to the regional hospital boards the right of appointing their own chairman and vice-chairman.
I do not know whether the Minister has any criticism to offer of the chairman and vice-chairman of the various regional health boards. If he has he should come out now openly and say what he considers to be unsatisfactory about them and about the way in which the existing method of election is operated. By and large, we have succeeded in the health boards in achieving a happy balance between medical skills and public persons in the selection of chairman and vice-chairman. If the Minister retains to himself this power of imposing a chairman and vice-chairman over these bodies he will be building in an ingredient of dispute. This is something which should be left as free as possible.
The Minister says he does not intend to have duplication and he rejects as an argument against the new structure of the health services that which says there will be more duplication and overlapping than ever before. He says he proposes to leave it to the councils to operate independently and give the Department advice, upon which advice the Department will apparently act, if we understand the Minister correctly, without further major disagreement. If the Minister is trying to sell these councils on the basis of setting up reasonably independent and competent authorities, then he ought to go the whole way and give full proof of his faith in these bodies by saying that he will allow them to elect their own chairman and vice-chairman.
One of the most alarming developments in the last year was the fact that the Minister considered it necessary to increase hospital charges by 50 per cent in one go. In this day and age of McKinsey, of computers, of modern management and planning skill, we are entitled to ask: "What went wrong?" The Minister has clearly shown in one very definite act that despite all the skills and all the planning and advice available to him, dressed up in so much verbosity, there is something radically wrong with the operation of the health services and with the management of these health services by the Department of Health. When the whole accountancy system of the hospitals can go so much awry, so far off course, that a massive increase of 50 per cent has to be put on at one stroke, then there must be something very wrong indeed. This is the kind of thing which is bound to increase the suspicion in the public mind that we are not getting the kind of efficiency we should be getting, an efficiency the Minister apparently believes we are getting but the public could not possibly assume they are getting.
Is it not significant that the Minister finds it necessary in the year in which he increases the cost of home medical services by 1/20th to increase hospital charges by half? Here is further proof of the wisdom of the approach of both the Fine Gael and Labour parties to the whole sphere of health, an approach which would get us away from the most crippling aspect of all, that of hospital care.
The general medical practitioners and the general public are worried by some of the criticisms the Minister has offered about the new choice of doctor scheme. The Minister has suggested that there are some doctors making unnecessary calls to patients' homes. He has suggested, if not directly certainly by inference, that doctors, instead of examining patients in their own surgeries at a lesser cost, are making far too many calls to patients' homes.
I would ask the Minister to consider what is almost certainly one aspect of this: until now it was often with the greatest difficulty that a dispensary patient could get the dispensary doctor to visit a patient in the home. This was not simply a physical reluctance in many cases on the part of the doctors to go to the homes; it was simply because their work load was so great that they could not possibly, in any working day, take in the number of domiciliary visits required by their patients. Of necessity they had to require many people who should not have been out of bed to attend the local dispensary. As has happened so often in the past where some small advance has been made in the medical sphere the cost has, perhaps, exceeded the original estimate because the original estimate was based on the fallacious assumption that people's pattern of behaviour would continue in the future as it had been in the past.
We, in Fine Gael, are certain that even with such progress as has been made in extending benefits both in number and degree, there are still vast numbers of people not getting the kind of medical attention they require from a medical point of view. There are still many families and many patients who do not purchase the prescriptions prescribed for them because the cost is prohibitive. There are still people in the 70 per cent who do not get any assistance in respect of domiciliary care, who do not call the doctor to their homes because they could not afford to pay the fee of £2 or more in many cases, particularly in rural Ireland, required in respect of a home visit. I believe that what has happened is not that doctors are abusing the scheme: I doubt if there are any, certainly not very many, abusing it; but I am certain that the choice of doctor now having become available and there being a greater number of doctors providing the domiciliary service and the care outside hospitals, people are now getting doctors to their homes, whereas previously they would not have done so.
If the Minister says this requires careful examination we would certainly agree but we would think it wholly undesirable that any brake should be applied which would have the effect of depriving people of the attention of a doctor at home when they should be confined to bed. We must be very careful here not to overstep the mark and as a consequence become rather inhuman and, perhaps, also ultimately increase the time required to cure patients.
The Minister has also suggested that there is exorbitant prescribing. This is a standard allegation of the Department. I have waited for a long time to find any substantial evidence of this. It is an allegation which is offered as an excuse for the multiplying increase in the cost of drugs and medicines which are certainly increasing in cost per item because of increased sophistication, something we cannot avoid, but I think the Minister will accept that one of the principal benefits of these modern drugs and medicines is that they substantially reduce the medical attention required. If I compare my own childhood with that of my children I know that whenever the common family diseases of measles, mumps, chicken pox and so on occurred the doctor seemed to be a daily visitor. One saw the doctor so often that he became like a piece of family furniture. Now, when children succumb to any of these diseases there is one call or at most two by the family doctor. The old, very personal relationships between families and doctors do not now exist to anything like the previous extent, primarily, I think, due to the beneficial effect of modern drugs and medicines.
So, let us not carp too much about these costs. I believe they are substantially beneficial in the purely economic sense because, if you like, they reduce the incomes of doctors and, therefore, the levies doctors make on incomes. I think doctors are sufficiently alert to the real medical dangers of overprescribing. Under the old system of no choice of doctor where, particularly in housing areas of large families, doctors were overloaded with cases, there might have been a tendency to prescribe larger quantities than might be prudent but it was either a question of doing that to avoid repetitious calls by patients or else the whole system broke down. With respect, I say the Minister cannot have it both ways: either the doctors prescribe adequate quantities of drugs or medicines or there will be increased charges for additional calls at the patient's home or at the surgery. This is not to say that we should not have all accounts carefully examined and should not assist doctors in keeping down unnecessary expenditure: we certainly should. This is most desirable and we encourage the Minister in this but let us also take into account the other considerations which are certainly as valid as those the Minister offered. My only regret is that when the Minister touched on the subject he did not also present the other side of the coin.
That is as much as I can usefully say. I am sorry that I found myself suddenly injected back to Health out of Foreign Affairs. We appreciate very much, indeed, what the present Minister is doing in this sphere. I think he has found, what so many of us have found in serving on health authorities, that the whole sphere of public and private health is a most satisfying one and, perhaps, one of the most rewarding because one sees such immediate and direct benefits from what one does. It is also a frustrating one in that I am sure the Minister would like to be doing a great deal more but the Minister for Finance does not always think the same way as the Minister for Health. The Minister can be assured that any help he can get from these benches to assist in loosening those purse strings so that we will have a greater flow of money into the very important sphere of physical and mental health, will be forthcoming.
It is a short time since we had the previous Estimate for the Department of Health and I thought most of the Minister's speech today was just a rehash of what he said a short while ago. Nevertheless, I commend the Minister whom I have always understood to be very conservative for some radical changes in his Department and for his radical approach to the whole matter of health services.
There are some points to which I wish to refer because I think this is a very important Estimate since it concerns so many. I wish to refer to the choice of doctor scheme in view of the Minister's remarks about the number of visits per patient being in excess of what he anticipated. I should like to draw his attention to various statements I made in this House on this subject when I told the Minister he was badly advised in basing, as he did, the number of visits by a doctor per year on the British estimate which was 2½ visits per year per patient. He thought we might be a little more. To my knowledge he based it on 3½ visits per year. He failed to take into account the fact that here we are providing a choice of doctor scheme for the lower income group, the poor, the underprivileged, persons more subject to illness and disability and who would make a bigger demand on the doctor. This is where the Minister and his Department have failed, despite the fact that I brought this matter to his attention on many occasions. If the choice of doctor scheme applied to the entire country and were not confined to the lower income group we would have 3½ visits per patient per year. Taking the lower income group the figure is nearer to seven or eight. The Minister's calculations are completely wrong. I want to bring this point to his attention because he refuses to give details of the basis of his calculation. I am telling him now where he made a mistake.
The Minister referred to over-prescribing of drugs. I am conscious of the fact that people may rely too much on drugs and we doctors have a responsibility to explain to patients the need for a healthy attitude towards drugs in general. The Minister should bear in mind some very important points. When a family doctor is confronted with a case of organic illness, whooping cough, measles, pneumonia or fever, he has to decide whether to send the patient to, say, a teaching hospital in Dublin, where it will cost £98 a week, or to prescribe for the patient. The costs are reduced enormously if the doctor decides to prescribe because in that case there is no demand for a hospital bed. In doing this he takes on himself a tremendous responsibility. He must prescribe drugs. In a hospital the patient can be under the observation of trained personnel every two hours. A family doctor could not provide that kind of service. He must resort to prescribing drugs, antibiotic drugs in the case of fevers.
Everything is all right for those doctors who are in positions and who do not understand the complexities of general practice. When a doctor in general practice attends a patient the whole responsibility is placed on him. He has other patients to attend to. He is justified in prescribing drugs. He cannot leave the patient without adequate treatment. The Minister should bear this fact in mind and should have regard to the responsibility that there is on doctors. If the Minister imposes a limitation on a doctor's right to prescribe drugs, especially in the case of the lower and middle income groups, he immediately opens the floodgates of demand for admission to hospital, in which case the cost is enormous. A hospital bed costs £14 per day. The logical thing to do is to allow the doctor to treat the patient at home.
Where possible, I try not to have patients admitted to hospital. I tell them that it will cost £98 per week and that they can be treated at home but that if their condition worsens they will be admitted to hospital. There is an obligation on doctors not to have unnecessary admissions to hospital. The psychotropic drugs, tranquillisers and anti-depressants are prescribed because doctors are faced with enormous social problems. In this city they meet social problems that do not affect the Minister for Health, problems associated with overcrowding, the separation of husbands and wives because of lack of accommodation, which give rise to severe depression. Doctors cannot provide accommodation. They can treat the sufferers symptomatically. The whole system is wrong. In order to stop the prescription of drugs the system would have to be altered. There is a very big problem which is not being solved. Doctors treat symptomatically the terrible problems of overcrowding, alcoholism and so on. The right thing to do would be to correct the causative factor. Doctors are unable to do that.
We should clear up points about the choice of doctor scheme. I am very pleased by the Minister's advice to chief executive officers of health boards in regard to the formulation of a uniform set of guidelines. Mr. O'Keeffe of the Eastern Health Board has been to the fore in setting out a set of guidelines which, in my view, are very good. I should like to see them being given more publicity because people are still in doubt as to their entitlement to medical cards. I should like to compliment the author of these guidelines. I congratulate the Minister on what he has done in this regard. It is magnificent work on his part and he must be congratulated. It means that people can get some idea of their entitlement. A person with two children and an income of £20 a week can get a medical card. Of course there are borderline cases. These guidelines should be publicised. Despite what is said, people still do not know their rights in this regard. There is a very good morning radio programme on rights under the social services. It might be possible to make more use of the radio for the purpose of informing the people of the arrangements within regional health boards. It is not possible to have a uniform method for the whole country under the present system.
The facilities for coping with applications in the Eastern Health Board region are bad. Applications are being lost or mislaid, the income forms which must be submitted are being lost and people are compelled to go again to their employers. I have mentioned this to the health board but I do not know if anything will come of it. There should be some way of making the lives of these officers a little easier so that they could cope with the inundating number of applications coming to them at the moment. They can do it only if they have proper facilities.
The scheme to assist in the cost of drugs is very good and I find complaints only in so far as people come to me with them. One complaint is the waiting for a month to get a rebate. There are people in that grey area just above the limit of eligibility who have a lot of demands on their incomes and who cannot afford the money at the time. Perhaps that time gap could be narrowed and thus the burden eased on people who find it difficult in any case to find the initial payment.
Hospital costs are a considerable concern to a number of people at the moment. The recent announcement of an 80 per cent increase came as a blow to a big number of people, particularly because there had not been a proper costing system employed. I should have thought the Department would have waited until some kind of investigation into the hospital charges and costing had been done. That would have been seen by the public as a sincere effort by the Department to keep down costs.
We realise that a number of hospitals have unnecessary admissions and that the patients spend an unnecessary number of days in them. I have said over and over again that patients admitted on Friday are not examined until Monday—that they need not be there during the weekend. That would be one way to cut down costs. Also there should be some method of streamlining out patients' departments. We should also provide proper diagnostic facilities, properly co-ordinated. This might prevent people being admitted to hospital or at least reduce the number of days spent by people in hospital. We might also devise some means whereby patients would be seen by family doctors in consultation with a consultant, thereby limiting admissions. We might even arrange to pay a fee to a consultant to attend at health centres. When we think of the charge of £14 a day we must consider seriously some suggestions such as those I have made.
There is also the problem of geriatric patients in teaching hospitals at £98 a week. Is there any way in which we could give those people extra grants or in some other way prevent unnecessary stays in hospital? Could the Minister for Health consult with the Minister for Social Welfare in this? I do not think, for instance, that the £2 a week given to relatives to take care of such people is sufficient.
A number of such patients are admitted for surgical reasons but then there is nobody to take care of them afterwards. To remedy this, could we license private homes which we could keep under regular inspection? I am concerned about people who do not need medical care afterwards. I know of a person who is in a hospital in Dublin and the hospital authorities have said they need the bed. However, there is no place to put the patient in. That patient does not require medical care. I know we cannot keep on building hospitals or homes but I suggest we should license existing buildings where such people might be cared for.
When we are designing hospitals should we not provide accommodation for people who come to Dublin for examination? There is one hotel, the Royal Hotel in Bray, which is operating a nursing hostel for geriatrics. Patients can stay in the hostel and there is a nurse on duty. The fee is £20 per week. It is a commercial venture. It is a most desirable alternative to the patient having to spend some time in hospital where there is labour intensive with highly skilled personnel and consequent high cost. In these circumstances we must look seriously at the problem of reducing costs.
I wish to deal now with psychiatric treatment. I know there has been a reduction in admissions during the years but many patients have become institutionalised and they need to be encouraged to leave hospitals. Such facilities are provided in St. Gabriel's in Dublin where the doctor is doing tremendous work to get patients out of St. Brendan's and to bring them along the road of rehabilitation out of mental hospitals. That man should be given all the facilities we can offer. The people I am concerned with are those who have been institutionalised and who are afraid to face life again. St. Gabriel's is the half-way house in this treatment. We need several hostels to accommodate such people during their rehabilitation. As I have said, I am referring particularly to chronic patients who are afraid to face life.
I suggest that we should encourage more patients to go to see their family doctors. I think thereby we would avoid much of the high cost of hospitalisation. After all, the family doctor is the best person to help such people to cope with their problems. I appreciate that the Minister has a consultative council and, perhaps, they might consider this suggestion. I am referring to patients with terminal stage cancer or other illnesses who are in severe pain and who need constant attention. These people could be housed in units attached to general hospitals. This morning I had a phone call about a man who is in terminal stage cancer and who needed a doctor to give him injections three or four times a day. The family could not afford the cost involved but, unfortunately, they did not know anything about home nursing services which might be available. I promised the family that a nurse would call to see the man. It is an impossible burden for people to bear the cost of a doctor's visits a few times each day. We should give serious consideration to having small units attached to hospitals where this kind of patient could be treated.
With our modern therapy we are not curing cancer; we are prolonging life. We have an obligation to do this but, unfortunately, sometimes patients must endure long periods of agony and we should ensure that they get the necessary medical attention. If we had the smaller units, family doctors could treat their patients and we might have a nursing service which would be better and more intensive than is presently available for these people. I realise that the Minister has a lot to do, but this is a serious problem and he should give it careful thought. Hospitals tell patients with terminal stage cancer that they cannot do anything for them, but we cannot set these people aside.
The Minister has mentioned coordination of the activities of cancer hospitals. Again, I would ask him to delete the word "cancer" from the name of the hospital. It will take many years to eliminate the fear created by this disease. When a doctor has to tell a patient he is sending him to a cancer hospital, the patient thinks he has received a death warrant. I should have a dreadful fear if a doctor examined me and told me I had to go to St. Luke's Cancer Hospital. It was ridiculous to have called it that name. I am sure all Members would have the same fear.
We should arrange to have cancer units in the general hospitals or, if that cannot be done, we should introduce some other aspect of medicine into the hospitals in order to take away the stigma that attaches to cancer hospitals. We can continue cancer therapy in these hospitals, but they should not be used exclusively for cancer patients. I know the psychological trauma on patients when they are told they must go to a cancer hospital; it is almost a death warrant.
I should like to comment on the shortage of maternity beds. I fault the Department and the maternity hospitals for not taking account of the fact that today most women go into hospital to have their babies. It is rare nowadays to find a patient who wants to have her baby at home. However, this is creating a serious shortage of beds in our hospitals. When the Coombe Hospital was built, sufficient accommodation was not provided. In my practice I saw the changing pattern and I wondered why we did not provide more beds.
I would ask the Minister if it is possible to provide maternity units attached to hospitals. The family doctor could deliver the patient, using all the facilities available in the hospital. It is not necessary to build enormous structures; the construction of pre-fabs would be suitable because we could adapt to changing patterns and trends. We may get to the stage where it will not be necessary to extend the Coombe Hospital—in my view it was poorly sited, in any event —if we provide these additional units. Ultimately we may be able to provide this accommodation in health centres in the community.
I had a question down today with regard to the high abortion rate of Irish women. It is because of the lack of education here that girls go to Britain for abortions. They do not realise it is murder. I have talked to many patients and I have succeeded in persuading them not to go to Britain. Recently, there was a court case in Britain regarding a woman who had an abortion and suffered terrible consequences. She had the abortion in a clinic in London; in such places abortions are carried out and within 20 minutes the taxi comes along to collect the patient. The woman to whom I have referred was expected to return on the boat to Ireland that night. She had a major operation afterwards here; in the court case in England the doctor was convicted of negligence.
A consultant has said that there are 50 Irish girls each month who come to his hospital in London for abortions. It is no use our saying that this does not exist. We should look at the matter and see what we can do about it. I am not saying that we should advocate a promiscuous situation here, but there is a need for education in family planning. As I have said before, we subscribed to the United Nations Conference in Teheran in 1968 which advocated that family planning be available to all people as a matter of right. Our Department of Foreign Affairs were represented at that conference and we were signatories to that document. Yet, we are depriving people of the right to education about family planning. A family planning programme should be made available on a national scale; it should be organised in hospital clinics. By educating our people in this respect we will be preventing murders. We stand indicted if we do not do something about it. Such clinics should be financed by the health boards and conducted at maternity hospitals.
I come now to the question of drug abuse and alcoholism. The Minister talked about an inter-departmental committee and what they would do but in this respect he omitted the salient point which is that if drug abusers must be treated they must also be rehabilitated. We are not doing this. They are being treated but sent back to the environment from which they came. This is not solving the problem. We are not providing the therapeutic beds for these people. Neither are we providing hostels for them. In the first place we must face the fact that there is a problem of drug abuse in this country and that LSD is being abused on a serious scale here. When problems exist they should be tackled. The first thing to do is to consider how best we can eliminate the cause of this problem. There has been unnecessary delay in the introduction of the legislation that is required to deal with trafficking in drugs and with drug abuse. There are people who are trying seriously to cope with this problem. In fact, there are exdrug addicts involved in this work. I have had a communication from one group who are so involved but no facilities are being made available to them to help them in their efforts. This group seek a house which they can use to provide hostel accommodation for drug addicts so as to get them away from the drug environment. The provision of such facilities might be regarded as an investment in our country in that it will help solve the problem, a problem which will become worse unless we take action now. In Britain and the United States the problem was ignored for too long so that by the time it was decided to take action, it was too late. Unless we take advantage of the opportunity that we have now of coping with drug abuse, we may find that it will become too great for us.
I would ask the Minister to discuss seriously with the Pharmaceutical Society and the Irish Drug Association the possibility of having pharmacies open during the night in our cities and towns. It may be said that the doctors carry with them the requisites for emergencies but this is not so. In attending to a member of this House a few weeks ago I was unable to find a chemist's shop open where I could buy what was required. It should be possible for the Irish Drug Association to arrange to have one pharmacy open in a central place in each of our cities and towns all through the night.
Last week I endeavoured to raise on the Adjournment the question of fire hazards in hospitals. The Ceann Comhairle did not permit me to raise the question but said it might be raised during the debate on the Estimate. This brings me to the whole question of a possible national disaster in this country, something which we are inclined to think could not happen. On another occasion I should like to develop the question of a national disaster plan. From my knowledge I believe we could not cope with a national disaster. I am aware that when our plan was carried out experimentally it proved to be a fiasco. If, say, there was a plane crash at Dublin Airport and if there were many people injured we would not have the required number of hospital beds to cope with the casualties. Regarding fire hazards in hospitals, I might mention an instance of which I was writing a couple of months ago. This concerned a hospital in Nenagh where there was only one nurse on night duty to cater for 40 patients. In the event of fire how could that nurse possibly bring all these patients to safety? It is difficult enough in the case of fire to help people who are well but the task would be very great when those concerned would be ill and, perhaps, bedridden. The fire brigade officers' association have pinpointed this danger. The matter is one to which urgent attention should be given.
Another matter to which I wish to refer concerns the giving of State aid of £4.5 million to one hospital in Dublin. The nuns in that particular hospital have provided a magnificent service to the poor of Dublin for generations. They were doing a very important job but now one cannot be treated in that hospital at a rate that is lower than anywhere else so I am beginning to wonder about this £4.5 million. This amount of money is being given to an inanimate object— an Order—and not one nun benefits personally from it. The nuns in question have sold their own property for £1.6 million and are concentrating on a private nursing home. I am questioning the reasoning behind the granting of this money.
If our health services did not provide for the lower income groups, I would say that these nuns should be given twice that amount but the point is that they are not providing a service for the poor. Even the nuns should consider this matter and ask themselves whether it is correct for them to receive this money. Maybe they have lost sight of the fact that the opportunity of treating the poor does not arise any more in their case so that they might turn their attention to some other sphere. If I thought that the money was to be deployed for, say, necessary social work of one kind or another, I would say let them have the money by all means but on the basis of the facts presented to me I am not happy that they are right in what they are doing.
The last matter to which I should like to refer is the question of the hospitals bodies regulations. I am not very happy with the regulations as presented to the House by the Minister. The proposals for the creation of the regional health board emanated from the FitzGerald Report. That report was completed in 1968 and was welcomed by all parties especially by those interested particularly in the development of the hospital services. It was accepted in principle by the then Minister for Health. The report envisaged the creation of a co-ordinating hospital system which, it said, was an essential prerequisite to what is the unification of the consultant pool into one national organisation. It was envisaged that all new consultative appointments should be advertised and subject to open competition. We all assumed that the Minister was accepting this and that health board hospitals and voluntary hospitals would have a common method of selection of consultants for appointment to the hospitals so that there could be an exchange of consultants between the health board hospitals and the voluntary hospitals. Everything looked grand.
I do not approve of the method of selection by the Local Appointments Commission of applicants because I think it is too rigid. It fails to take account of personal factors. They base everything on what they receive by way of written recommendation. If I were asked to submit a reference for a person I might write one thing but if I were phoned and asked for a private one I might give a completely different one. This is where the Local Appointments Commission have failed. They failed to take into account other factors. I knew one person who had the academic qualifications but was a flop from the point of view of medicine because he lacked that indefinable something which makes a doctor.
The Minister's capitulation to the voluntary hospital in present circumstances is wrong. He has not implemented the proposals in the Fitzgerald Report. They proposed that the consultant pool should be unified into a nationwide organisation, that all consultant appointments should be held under the regional hospital boards, that new consultant appointments should be the subject of competition and that all consultants already appointed to voluntary hospitals should have a new contact with the hospital boards. This was agreed to and everything was perfect except that in November last a statement was made on behalf of certain hospitals in the Dublin area to the effect that they would agree to this only if those selected by the hospital boards met the requirements of certain voluntary hospitals in Dublin.
This was a direct challenge to the Minister. It was said that they would not accept the common method of selection except where it suited them. They reserve to themselves the right to make their own appointments. This was flouting the new system recommended in the FitzGerald Report which was agreed to by the previous Minister and which I thought was being implemented by the Minister. It was an open challenge to the Minister and he did not accept the challenge. He should have said: "I do not accept it. The new regional hospital boards will make the appointment to voluntary hospitals and to hospital board area hospitals." Instead of that he capitulated and the new draft regulations are such that it is obvious that he did.
We cannot have these regulations amended. The Minister presents them to the House and that is final. In view of the serious concern which is felt by the Medical Union and the IMA I would ask the Minister to reconsider them. They have both stated that they are opposed to the Minister's regulations in their present form. They have suggested that the common method of selection of consultants for these hospital posts should be introduced as soon as possible. The Minister should seriously reconsider the whole matter in view of what I have said. If he does not the hospital boards will be emasculated. They might as well not be established. The matter could be left in the hands of the health boards as they are and the voluntary hospital boards could continue with their own method of selection.
If the Minister keeps the regulations in their present form, there will be no way of avoiding charges of nepotism in hospital appointments. He had the opportunity. We could have arrived at a compromise method of selection which could have been acceptable to the voluntary hospitals, the Medical Union, the IMA and the medical profession in general. His new draft regulations are pitiable. I would ask him to consider a new method of selection, a common method of selection which would not necessarily be that of the Local Appointments Commission. We could have a new independent tribunal or board on which the voluntary hospitals would be represented to assist in the method of selection. If we did this we would create harmony among the doctors involved and we would put an end to this dichotomy which is so obvious in the appointments system of the hospitals. If the Minister has another look at this and has further consultations with the interests concerned he will be doing a good job.
The Minister said that in the setting up of the regional hospital boards all those with a direct interest should be represented on them. Will he include family doctors, because they have a very important role to play on regional hospital boards? By doing this he would get adequate representation and he would ensure that their point of view would be heard, understood, and made known. The hospital boards would benefit accordingly.
I should like to compliment the Minister and his staff on this magnificent Estimate. Not only is it an Estimate but it is also an encyclopedia of very useful, enlightening and encouraging information on the trends of the health services and on the hospital building and rebuilding programme. We learn with satisfaction that the cost of the administration of the services is a mere 3½ per cent. From time to time different figures have been given by critics of the services and other outside people. In this Estimate we are spending £86½ million which is £13 million more than last year. By this time next year the Estimate will probably be for £100 million, which is quite a lot of money for a small country like this. I am sure nobody will grudge one penny of it, if it means, as I am sure it will, a better public health system which will provide the best treatment for a person who becomes ill.
The Minister pointed out that, thanks to Government subsidies towards the health services, the impact on the municipal rates was not as great as it might have been. This is very true. The Government and the State are to be complimented on giving such vast subventions so that the burden of the rates will be reduced in respect of health services. There is a fairly widespread demand that the burden of cost of these health services should be removed from the rates. I do not altogether subscribe to this school of thought. If the rates were relieved many very big concerns would escape paying even part of the cost of the health services and ordinary men and women would have to pay much more by way of taxation. That would impose a burden on parents with young children. I know one case in which the burden of rates actually caused mental illness. I do not say that was the only cause; there may have been other causes too. Young parents trying to rear families find the rates an almost intolerable burden. I welcome the Minister's farsightedness in planning and doing everything possible in an effort to reduce the burden of health charges on the rates.
We must not become complacent. The State will have to take on more and more of the cost of the health services. At the moment they contribute the greatest single item in the rates. There will have to be increasing State subventions to reduce the burden of cost of health services on the rates. The Government have been generous and I trust that next year we will see even bigger subventions from central funds towards the cost of health services.
All over the country hospitals are being modernised. We have all the details here in this massive document. Surely the wind must be taken out of the critics' sails by this document. In time we will get rid of the old hospitals, some of them the remains of old workhouses. As one who serves on the board of a voluntary hospital, I know the amount that can be spent on patching up an old building. This is a very good hospital, but it is one of the oldest in these islands. Vast sums have been spent in keeping the building standing.
I commend the Minister on this building programme. I should like the Minister to tell us the approximate date when these old hospitals will be demolished. They have served their purpose and it is false economy to go on patching them up. They should be replaced temporarily by prefabricated buildings. That would lead to improvement all round for patients, medical staff, nursing staff, administrators and others. The biggest problem is trying to carry on a twentieth century medical service in an eighteenth century building.
There are those among us who take every opportunity to tilt at the religious orders and to question what they do with their money. Their money? It seems to be an in-thing to criticise religious orders, whether it be in the field of education or in the field of medicine. It is the in-thing to suggest, by innuendo, that the religious orders are not exactly doing what they are doing for nothing. Medical services go back to the Knights Hospitallers. It was the religious orders who started and perfected medical services. We are living in a more secular society now, a society reluctant to say "Thank you" for what has been done or what is being done. There are those who suggest that running medical services is a money-making business. When these religious started these hospitals nobody asked where they were getting the money. They went around the cities and towns in the eighteenth and nine-teenth centuries begging for the funds necessary to start these hospitals, hospitals in which they succoured the poor.
We have now reached the stage where the State is taking over more of these services and there are those who suggest that we can now disown and get rid of the institutions run by religious. They allege that the money they get for the sale of their property should be inquired into and that we should probe into what will be done with that money. It might equally well be argued by these people that we should probe into what a doctor or a teacher does with his or her money. We have surely reached the era of "Big Brother" when it is suggested that we must probe into what is done with the money paid for an old hospital. It is time this attitude changed. There is an order of nuns in this city who for many years provided a home for homeless women. They are now turning to providing a home for old people. The Department and the Eastern Health Board will provide certain grants, but the rest will have to come from the pockets of the ordinary people. I have no doubt it will come willingly. With that type of system we should have a much healthier society than some of the more advanced societies where the State does everything except provide that essential charity which must be the basis of all our hospital services.
We are having great things done under the Minister's programme for modernisation of hospital buildings and things will go on improving, but the out-patients' departments of city hospitals always cause me concern. One finds a long queue of people waiting for a doctor or surgeon for many hours through no fault of the doctor or surgeon who is probably over-worked. When the Minister is considering advance planning of hospitals this is one area to which special attention should be given in an effort to cut down the waiting time in out-patients' departments in practically every hospital in this city. It is not good even from the psychological point of view that people should endure these long waits, perhaps comparing illnesses, and filled with apprehension as to what they will hear when eventually they get inside the clinic door.
It is wrong in this enlightened age that one should have to wait perhaps two hours before being able to see a doctor. I serve on a voluntary hospital body and I know the difficulties. I am not criticising the staffs but with good management and perhaps more staff waiting time and apprehension of patients could be greatly reduced. They should not have to wait for hours and then perhaps not see the doctor or surgeon they want to see.
The Minister has given some heartening vital statistics. If we want to build the society we desire and ensure that from birth to death every citizen will have a reasonable health service there is a great challenge facing us. One very encouraging feature is the infant mortality rate which in 1970-71 was 18 deaths per 1,000 live births, the lowest on record, as was the maternal mortality rate at 0.16 per 1,000 live and still births. There was a time when Dublin had the highest infant mortality rate in Europe. While I do not know the comparative figures I would say that at last we are overcoming the grave problems we had for many years thanks to the work of successive Ministers and the Department.
Our life expectancy figures are on a par with those of Britain and Northern Ireland. The fact that people are living longer presents a great challenge to us. This is welcome but we must plan more than would have been the case ten years ago for a great increase in the population of old people. Thanks to modern drugs old age does not perhaps carry the same dread as it did 20 years or more ago. The Minister's speech revealed a gratifying reduction in the number of patients in mental hospitals, but anybody who visits these hospitals very often finds old people there because there is nobody to claim them. We should pursue a policy of providing bigger and better units for old people so that if they have no family to claim them they will get maximum comfort in their old age in proper hospitals, with proper geriatric services and everything possible done for them. Any civilisation may be judged by its treatment of old people. Despite the many calls on the Exchequer we are making a worthwhile effort and it must be expanded to ensure that our old people get the maximum comfort in their old age.
The Minister dealt with every aspect of health services and naturally the drug problem was mentioned. Without being an expert on the subject—if there are any experts—I think because of the publicity it gets, in the eyes of so many young people drug-taking is given a false glamour and, particularly those who smuggle in drugs and sell them are given a sort of James Bond image they certainly do not deserve. We should get it home to young people that this is a dirty, vicious habit and that they are being exploited by those who sell drugs. We should also make it plain to drug traffickers that they can expect no mercy. I suggest that in the case of non-nationals—and quite a few of them are operating here—the fact they are found guilty of having drugs should mean immediate expulsion from this country. I cannot imagine any country welcoming such persons because of the terrible damage they can do to young people by selling drugs to them and turning them into human wrecks for the sake of profit.
The Minister has taken considerable steps in this regard and one looks to him with confidence to sustain and expand his interest in this problem until it is reduced to the minimum. It is impossible to say whether the drug problem is large or small but, whatever its size, it is too much. All our energy and the necessary money must be devoted to ensuring that we will not become like other countries in regard to this matter. If it were possible to publicise the fact that Ireland is a tough place for drug pushers that would have a great impact in reducing the problem to very small proportions.
There are many problems associated with young people today. The Minister referred to alcoholism. There is a national council studying the problem of alcoholism to which most Members of the House have made submissions. The problem of alcoholism continues to increase. According to a newspaper article yesterday there are 70,000 alcoholics in this country. On the other hand, there is a large percentage of our population who are non-drinkers. Apart from those who are members of abstinence associations there are many people who do not drink. Therefore, if one takes the total consumption of drink the question arises as to whether those who drink do so to an extent that is well above the European average. I look forward with interest to the report of the council on alcoholism to supply the vital information which will help us to tackle the problem.
I should like to pay tribute to the Vintners Association for their work in schools and in other ways to show that abuse of drink is wrong. The Vintners Association have shown a very forward outlook. I compliment them on their attitude to the problem. They recognise that there is a problem and are helping to solve it. While marking my appreciation of what they are doing, I hope that it will be possible for them to do even more.
The Minister referred to the question of health education and dealt with what is being done and what will be done. His observations are most encouraging. He mentioned education in regard to drug abuse and abuse of alcohol. The last speaker suggested that abortion was murder. With that we would agree. He suggested that it was a consequence of the lack of family planning here, or used words to that effect. One thinks of countries where there is family planning, where all forms of contraception are used and where there is a really permissive society. Despite their planning, they have mammoth problems of abortion and of venereal disease. These problems must be studied and we should try to benefit from the experience of other countries where horrible problems have been created.
The Minister's plans for health education are down to earth and are geared to the needs of the Irish people. They cover a wide field. Naturally, he refers to cigarette smoking, overweight, overeating, all of which take their toll of health. The Minister also mentioned the problems of teenage drinking. He said that allegations have been made that some publicans serve drink to boys and girls under 18 years of age, which is illegal. In fairness to the publicans, it is very difficult to say whether a boy or girl is under or over 18 years of age.
Or whether it is a boy or a girl.
Quite right. That is an added problem. I do not think we should fault the publicans. Usually I am not a friend of publicans. The Minister said:
Proper upbringing of children by parents and school teachers is of fundamental importance in combatting alcoholism and drug abuse.
We are back again to the home, where the real education must take place, while it must also be realised that parents cannot follow their children through the city streets or the countryside. With society becoming more sophisticated, young persons are at greater risk. It is good to know that the Minister takes a broad view of health problems and is dealing very effectively with most, if not all, of them.
Most Deputies spend a great deal of time writing letters on behalf of constituents who are anxious to know their entitlement to medical cards. It is difficult to apply a rigid rule. At least, one seems to get replies to letters more quickly than used to be the case. I may be wrong but I always feel that medical cards are more difficult to obtain in Dublin than elsewhere. Last year statistics were produced which showed that the Dublin figure was much below the rural figure. There may be a good reason for this.
Higher incomes.
Generally, certainly, but it would be wrong to generalise. A man may have a good wage but he may have many domestic cares. He may be buying a house which, financially, he cannot afford, but which, from a practical point of view, he cannot afford to be without. With the expansion of our health services and more people becoming entitled to benefit from them it is only natural that some people will be hurt. This expansion has gone on for many years but the tempo has been more emphatic in recent years and while we bring benefits to a great number of people we will always have the odd hard nut with whom we will have to deal.
In a society like this we must ensure that every case is probed to the fullest. The fact that a person does not have a medical card does not mean he does not benefit under the health scheme. We must also remember that people who have health cards are generally at the lowest rung of the social ladder and that they need more care and attention than those who do not have to go to their local health boards to have their medical needs met. We could save a lot of time and administration costs if we had a scheme in which a person could mention his gross income and give particulars of his rent and the number of his children. Little things like that would help to save time and cost and people entitled to benefits would do so more quickly.
In his opening speech the Minister mentioned the food additive regulations issued in February last. They are aimed at controlling certain elements in food—preservatives, antioxidants, colouring agents and mineral hydrocarbons—and the Food Advisory Committee, we hope, will have a final report soon on this matter. When we enter the EEC we will be obliged to comply with their regulations in regard to food and drink, hygiene and so on. In most of these matters our standards are as high as those of the Europeans but in some we will have to catch up. The fact that we have an open mind in regard to such matters will help us to design, to effect and to operate worthwhile health services.
Despite the various attempts of the Minister to bring home to the public their entitlements under the health services, it is hard to get across to many people what they are entitled to. They will ask the most elementary questions and I cannot impress too strongly on the Minister, if that is needed, the importance of repeating to the public what they are entitled to and what they have to pay for, if anything.
The Minister has given us a magnificent résumé of his Estimate and the book on the capital budget prepared us for the Estimate. I hope the debate will repay the Minister's work and that many of the things we say will help him to improve the health services.
For those of us who have been here for a few years the record of legislation on health has been chequered. Many years ago I was invited as a member of the then Select Committee on Health to a function in Iveagh House. It was the coming together in peace and harmony of the then Minister for Health, Deputy Seán MacEntee, and the two medical trade unions. Unfortunately, at the end of six months things were more strained than they had been before the event when we thought the question of health would be moved out of that area of disagreement in which it had existed.
Two or three years before the issue of the FitzGerald Report, what is popularly known as the Brown Book, I had the experience of going to a senior officer of the Department of Health and pleading for more geriatric services, more geriatric beds, in my county and being told that there would be plenty of time for the Louth County Council to do their planning and to put up their proposals for improved geriatric services. I was told there would be no waiting period. Unfortunately, that did not prove to be correct and the need for these services is as great now as it ever was. The last act of Louth County Council before handing over to the health board was to give Hilltops Sanatorium over to the housing of geriatric patients. In the years intervening, there were delays and frustrations which could not then be blamed on anybody but which we must now face up to in the new background of regional health boards and the rest of it.
We now have a situation in which the two medical trade unions, the IMU and the IMA, can be regarded as the strongest unions in the country. I do not say that in any sense of criticism. My uncle was a country dispensary doctor practising down the road from where I live and I am fully aware, therefore, of the great strain on doctors. I am aware also that when politicians come to deal with health it becomes very like bread. We cannot get away from the fact that bread is a political thing, that it becomes difficult to increase the price of bread. The same applies to health. Every politician desires the provision of more and better health services and more and more hospital beds. He has this desire but he knows the bill must be paid.
One of the great expenses we have from the health point of view is the provision of professional services, whether it involves GPs or consultants. It is quite easy to see how a Minister, or any politician, might be of a mind to pay professional gentlemen less than their counterparts in other professions in which there would not be such a political interest and to demand from them more in terms of effort and hours worked. During those years there has built up a natural worry among doctors that they would be treated unfairly with the result that they banded themselves into two extremely strong and militant unions.
By and large, the concept of health boards is desirable. It is good that for the first time the doctors are represented on organisations that deal with health. The pressure exerted on the Minister, both inside and outside the House, that he should provide a majority for local authority representatives on the health boards was necessary. The local authority representatives who have been elected by the people should have a majority on the health boards. The decision of the Minister to change his mind on this matter was forced on him but it was the right decision to make.
I do not wish to be critical about the health boards but there are certain facts that should be brought to the notice of the House. The nominees of the medical profession on the health boards are nominees of the two medical unions. When I first attended as a member of the North-Eastern Health Board I though there would have been another method of selection but this was not so. I should have preferred to see a paediatrician, an orthopaedic surgeon, a psychiatrist, a representative of other medical specialists and a representative of the general practitioners rather than representatives from the medical unions. However, so far as I can see on the board on which I serve, these people have been tackling their responsibilities in a fair and proper way. The nominees of the Minister are political nominees. I have nothing against them; they work on the health boards with energy and honesty. I believe there are decent people in Fianna Fáil but it is well that the facts relating to the establishment of the health boards should be recorded.
Throughout the country there is considerable apprehension regarding the downgrading of surgical hospitals. There is one such hospital in my constituency but we must accept the fact that it is important to have a complete range of services available in hospitals. If patients can be treated in one hospital, they have a better chance of a quick recovery than if they were moved from one hospital to another. It must be realised that the larger hospitals will be in a better position to provide comprehensive services for patients than will the small cottage hospitals.
An industrial town with a population of 20,000 people, such as Dundalk, demands a 24-hour surgical service, a 24-hour maternity service, as well as general services. One must take account of the hinterland around an area; to downgrade a hospital in an area merely because of the fact that there is a larger hospital 30 miles away which provides a complete range of services would be a mistake. While we must accept that in 1972 it is essential to have larger hospitals providing a full range of services, equally, we must consider the effects of downgrading a smaller hospital on the population of the area and the hinterland.
It has been suggested that a hospital catering for a population of 300,000 people would be in a position to provide full services. Full services must be provided for every citizen, but to downgrade smaller hospitals to the stage where they are merely convalescent homes would be a mistake. However, I do not think this is the Minister's intention. I am happy to see that there is no proposal to downgrade the Louth County Hospital at Dundalk.
In the eastern area the dispensary system has been abolished and it will cease to operate in the remainder of the country as from 1st October next. Generally speaking, the dispensary system served us well. The doctors we knew down through the years provided a fair and generous service and were always kind and courteous to their patients. Sometimes, however, to use a colloquilalism they were "put upon" to an extent that was almost unbearable. They were called at night to deal with illnesses that could have been attended to during the day. Very often after doctors had completed their rounds they were telephoned and asked to go back, perhaps, ten miles to an area they had only left. It would be remiss of us if we did not express our thanks and our appreciation to them for the service they provided.
Their particular role is now being taken over by another system and we must admit that this new system is an improvement on the old one.
Mention has been made of religious orders and the payment to them of capital money for the provision of voluntary hospitals. Ireland has been extremely lucky during the years in having religious orders who were prepared to provide education and medical facilities at very little cost to the State. It is wrong for anyone to be critical of religious orders when one realises what they contributed to this country in the past. There is a place in our country for the religious orders, for the large number of men and women, who, down through the years, channelled their salaries into their Orders' funds. These moneys were used in the establishing and upkeep of hospitals and schools. To all of those people we owe a deep appreciation for what they have done. Although there is a falling off in the number of vocations to religious orders, there are still many people entering the religious life. These people are prepared in many cases to enter such orders as the Medical Missionaries of Mary and to work within that order for the remainder of their lives getting nothing in return but a little pocket money. People who have specialised in medicine forego salaries of, perhaps, £10,000 a year to devote their lives to the service of others. In his wisdom the Minister should take account of the service that can be provided by the religious orders. We have no reason to believe that their services will be any less in the future than they have been in the past.
When one thinks of those engaged in nursing, he might ask himself what remuneration could be adequate to compensate a nurse, either lay or religious, for the work they do in looking after some of the sad cases that we have all seen from time to time. I would suggest that no remuneration could be adequate to compensate them for the work they do. Again, we are very lucky in having orders such as St. John of God where there are men and women who are prepared to do this demanding work for very little return. As a result of the role played by religious orders in the health services of this country, we can boast of what must be almost the best health service in the world in relation to the amount of money it is costing us. In the US a person in the middle income group could not meet the cost of any protracted illness. Every medical expense there must be covered by insurance the cost of which is very high. Again, I thank the Minister for the information he gave us in his brief but when one considers the figures he should realise that were it not for the selflessness of the religious orders, our figures for health would be much greater.
For some years past there has been new thinking in regard to geriatric services although little has been done to have this thinking implemented. I suppose that the new domiciliary services and care will ease the pressure of demand for geriatric beds. In this regard the position is that all over the country geriatric beds were based on the old workhouse system and I would say that in only about one-third of the country is there a moving away from that. These workhouse buildings where many geriatric patients are accommodated yet are wholly unsuitable. I hesitate to dwell on what might happen in the case of there being a serious fire in any of those old buildings which may be five storeys high and have no lift.
There is a building of this kind in my own constituency in which the Sisters of Mercy are providing a wonderful service for the old people accommodated there. The food is good and there is excellent attention but there is still that awful thought that if by accident there should be a fire because of electric wires being nibbled by a rat or for some other reason, the consequences could be very serious. This question of fire hazards in such buildings should be very high on the Minister's priority list. About five years ago in America there was a fire in an orphanage in which many children died. The account of that tragedy was read with horror by people all over the world. There is a grave danger that we have been acommodating our geriatric patients in buildings that are fire hazards, and that we are still doing so. It should be high on the Minister's building priorities to do something about this at the earliest possible date.
So far as the domiciliary services are concerned, they are not getting off the ground as fast as they should. In my town of Drogheda, with a population of a few thousand under 20,000 people, we have a community centre. One nun is seconded from the Medical Missionaries of Mary and she and the Mercy nuns pay calls on old people. There are more opportunities for an expansion of the domiciliary services than are being availed of. In Drogheda and Dundalk there are excellent committees of married ladies and their husbands who provide a good service. Various organisations have done things such as going into St. John's Home and providing hot and cold water for the inmates. They gathered money for this purpose and the Louth County Council put up £ for £ against what they collected. If people were aware of what can be done by way of the domiciliary services, the provision of meals on wheels, and daily attention for old people living alone at home, a far greater effort would be made by voluntary organisations.
I want to advert now to my own county. The old people's homes of St. Mary's, Drogheda, the Blessed Oliver Plunket Hospital in Dundalk, and St. Joseph's, Ardee, while comfortable and warm, and while the old people are well looked after, have not got enough beds. In two cases at least our buildings are inadequate. They are three and four storey buildings without lifts, which are essential in case of fire. Over the years I have been trying to get something done about this. So far nothing has emerged from my efforts and the efforts of many other politicians and interested people in that area. Because they are comfortable the old people seem to be nobody's child, to mix metaphors. These people should be at the top of our priorities.
I want to remind the Minister of the situation in Trim where we have one of the finest old people's homes in the country. There are no steps in it. A wheelchair can be wheeled along the passages to bring an old person out into the sun on a day like today if he or she is not ambulant. That is not possible in the other buildings I am talking about, where an old person might be on the third or fourth floor. In the fever hospital in St. Mary's in Drogheda there are 29 beds, as far as I remember. This hospital is used for non-ambulant patients. The likelihood is that a bedridden patient might live in a bed for five or ten years and never be able to see the light of day. Such a person living at home would be moved to a room on the ground floor and if his or her health allowed it he or she could be taken out in a wheelchair to feel the fresh breeze once again in the open air.
In these establishments where so much is being done by the good nuns, the good workers, and the good nurses, they are hampered by the fact that there is no lift into which a wheelchair could be wheeled. Unless they can walk up and down three or four flights of stairs they must live in the ward in which they sleep. I want to be quite specific about this. The people in these institutions in most cases have to eat, read, watch television if there is television, listen to the radio, talk to their neighbours, play cards and spend their whole lives sitting on the bed in which they sleep at night. This is not good enough. I feel strongly enough about this to delay the House, which I do not usually do on something which might be regarded as a trifle parochial.
I expect the Minister, for whom I have the highest regard, to take account of what I am saying. In my county of Louth these situations exist. God forbid that there should be a fire. Everyone of us has a degree of responsibility if there is a fire: the local authority members on the question of whether we pressed hard enough, the Minister and his predecessors on the question of whether they should have taken steps before now, the officials of the Department and the local authority, and the members of the North Eastern Regional Health Board, their officials and their chief executive officer. Two of the members of the board, Deputy Tully and I, are here. We must all face our responsibility for the inadequate geriatric accommodation provided and the fire hazard which I mentioned.
In relation to the regional hospital boards and the health boards, in most cases if the other health boards are mirrored in their activities by the one of which I am a member, at this stage they are only getting off the ground. We have made certain decisions about the provision of an extra orthopaedic surgeon. We are now in the process of paying visits to the various institutions under our control. To some extent this is a fact-finding mission. It may be 12 months or perhaps longer before these health boards get down to decision-making and to activities which are proper to them which will speed up the work which must be done.
The regional hospital boards are necessary if we have health boards. We must look at the various facets of medicine which we must provide for patients. We have to decide whether it is necessary to have a 50 bed unit in one place rather than three 16 to 17 bed units scattered over different areas and whether it is proper to have consultants and specialists travelling from one hospital to another rather than assembling patients in one place. It may be that in regard to certain illnesses and certain treatments it is necessary to have all the patients in the same place, notwithstanding the fact that their relatives and friends may be very annoyed at the long distances they have to travel to see them.
If attention is necessary many times a day or even two or three times a day and if it is specialist attention, if it is necessary for the curing of their illnesses that the specialist should see them every day, I do not know how it is possible to provide that service unless you can assemble quite a large number of patients in one place. On the other hand, if it were the case that a specialist need only see a patient once a week or once a fortnight, it might be possible to move Mohammed to the mountain instead of the other way round. Specialists could travel from one area to another and I understand it is now the policy for specialists to provide services over a wider area where that is possible. We are, of course, limited to what is possible. We will have to have different decisions on the different treatments available for different illnesses. It is vitally necessary from this point of view that we should have a proper infra-structure, the large general hospital and the essential services for the units of population to which I have already referred. Simultaneously we will have to have the large regional hospital and the requisite boards to administer the essential services in order to avoid diffusion of effort. We must ensure that the effort and the money invested and the professional expertise available give us the best possible return. The direction foreshadowed in the Minister's opening statement is the first essential.
With regard to costs, the Minister has indicated that there is an increase of the order of 4 per cent this year and it is expected that the normal increase in subsequent years will be of the order of about 3 per cent. This brings me to the question as to whether or not health should be a charge on the rates. It is the policy of my party that health charges, outside of hospitalisation, should be removed from the rates. That would be a considerable alleviation. Some years ago the alleviation was calculated at 4s in the £ on average. Today that 4s would probably be three or four times as much. It is becoming more and more obvious now that the cost of our health services will have to be met by indirect taxation. The money needed will never be found from any other source. Whether or not this would be a proper method of raising the money to pay for our health services is a matter for debate.
While the Minister has given some alleviation, it is not enough and, in the not too distant future, I fear some Cabinet will have to grasp the nettle firmly and decide that the cost of health will have to be borne from central funds. There is no other way in which it will be possible to meet the cost and we are merely putting off the evil day when a Minister for Finance will have to come in here with a proposal for increased taxation to meet this huge impost. It is not exactly healthy for someone on this side of the House to be suggesting more taxation, but overburdened ratepayers have reached the limit of their ability to pay. The cruel and unjust thing about rates is that they take no account of income. Where a person can prove that he cannot pay his rates and is, therefore, not required to pay them, the fact is that the other ratepayers must pay them for him by an increase in their rates. I believe the percentage increases adumbrated by the Minister will be exceeded. I have had experience as a member of a health board and, in order to provide better services, extra expenses will have to be incurred. As I said, the cost will have to be met from central funds and not by the overburdened ratepayers.
There is a figure of an increase of £.25 million for improving school dental services. School dental services are almost non-existent. Dental services for the population as a whole, apart from insured workers, are limited to those who can afford to pay. In Louth, prior to the health board taking over, our dental services extended to expectant mothers whose teeth were deteriorating rapidly. In many cases doctors put these people into hospital. In hospital they could sell the regulations a dummy pass and get these people's teeth attended to on the grounds that the deterioration was a serious hazard to their general health. There was, too, a yearly examination of children in school. Surely that could not be regarded as a dental service. The services as far as the less well-off are concerned are totally inadequate and there will have to be a spectacular improvement. Numbers of people, such as non-contributory widow pensioners and those on small incomes, small farmers on bad land in the west of Ireland, self-employed people, cannot afford to have their teeth attended to and the result is the teeth simply fall out of their heads, putting their general health at hazard. This is a problem which should be dealt with more vigorously. I see no evidence of any zeal on the part of the Minister to fill this lacuna in our health services.
On the subject of the mentally handicapped, I live close to St. Mary's in Drumcar and I know the wonderful work being done by the Brothers of St. John of God. I know the wonderful work being done by girls and boys, mostly girls, who come there to train; in most cases they stay there until they get married or they go to work in some other St. John of God institution. I have had experience of trying to get boys into this institution. It is heartbreaking to see the whole structure of a family grossly interfered with because of a mentally retarded child. The mother's health is very often affected. It is on this child that all the love and affection are lavished. This is the natural approach of parents to their children. It is not the child who is brilliant, or strong, or proficient at games who enjoys the lavish affection and love of the parents; it is the one who needs help, the mentally retarded, the weak, the child that is, perhaps, not bright at lessons, the child who has constant colds and 'flu and has to be muffled up all winter.
I have seen a boy of 13, not yet in ordinary clothes, lying on a couch being attended by his mother who was smaller than he was. Lord rest him, he is dead now. Although they had nine other children they would not let him out of the house. It must be accepted that the presence of the child in the house affected the normal family life and, although it may seem brutal to say it, it is conceivable that the other boys and girls of the family would grow up to be different men and women if they had not a severely handicapped child in the family. Just as geriatric patients cannot be properly attended to in the home because it is a 24 hour a day job and can only be properly looked after by being brought into a group of other similar patients where they will have a 24 hours service, so it is not possible to give the mentally retarded child the chance in life it should have within the home. The mother will tire at some stage although it is amazing how much she can do.
As I know from St. John of God's at Drumcar and other places, the association of retarded children with other children of the same level of intelligence and, perhaps, after a time the moving of the more successful ones into a group of higher intelligence, in which at first they might be the least intelligent, brings progress. It brings the mentally retarded child to its optimum in education and enjoyment of life. If it is isolated at home and allowed to grow into a cocoon it reaches adult life with a much lower level of intelligence and education than if it were properly trained in one of these excellent homes.
I believe the Minister is inhibited in his efforts in this regard only as were his predecessors, whether in inter-Party or Fianna Fáil days, by the number of vocations among boys and girls prepared to undertake this arduous and sometimes not very pleasant work. I hope and I believe that is so. I urge the Minister to place at the disposal of these good Brothers of St. John of God and all religious and others prepared to provide this service in the form of a day school or a residential establishment, all the money, buildings, equipment and encouragement we can give.
I am sure I speak for every individual in the House when I say there should be no sparing to provide the services I have described for every retarded child in the country. There seems to be an improvement in regard to the waiting list in the past year or so. I have no figures to show this but I know from my own political activity that fewer people approach me now seeking admission for a child. That means fewer people are disappointed because, I suppose, it is only the disappointed who come to politicians, but there is still a waiting list and there is need for expansion and the Minister would be very wise to press on with this as far as possible.
The programme is continuing.
I know that. The Minister will realise that I am not being critical. I am expressing a point of view which I believe the Minister shares.
The chief executive officers of the health boards and their staffs, as far as I know, are doing a good job. In our case we have a very small staff but we seem to be very lucky in that they have grasped the problem very quickly and seem to be well versed in all the difficulties arising in all the avenues in which we work. Their appointment, I know, was as a result of stringent examination and competition but we have been very lucky and my political colleagues tell me that the pattern seems to be the same all over the country. I hope the Minister will utilise the health boards and the advice he can get from their members, the good work and co-operation from the officials and, through his regional hospital boards and the health boards and the general structure established, and that he will press forward with the expansion of our health services and their improvement.
I have made my case in regard to my local concerns, mainly that Louth County Hospital should be preserved on the basis of the population it serves at least with the present level of services and that the geriatric homes in County Louth should be provided with lifts and should be extended to the stage where it will be possible to have admission after a very short waiting period. Health problems have now been faced up to by the doctors, the Minister and the country in a manner never before attempted. The structure advised by the consultants has, in broad general principle, been adopted and it is now up to us to complete the task, because this House is still the place where everything begins and ends.
There should be no restriction on capital moneys for the building of hospitals or the provision of services, but at the same time we should try to be as efficient as possible and get the best possible value for our money both in regard to capital expenditure and payment for services to all concerned. I hope our health services, our dental services, our services for the mentally handicapped, the paediatric and orthopaedic services and all others will be more efficient 12 months hence and more efficient on each occasion when we discuss this Estimate here than they were in the previous year.
The Minister for Health rose.
Surely the Minister was not serious?
There was only one other Deputy. I was not denying the Deputy his opportunity to speak.
I would hate to think you were. It would be a record if the Minister got away with that one. Everybody in the House has one object in view, that is, to improve the health services. I pay tribute to the Minister and his staff for doing what they think should be done to improve the services. I am sure the Minister will appreciate that my criticism of certain things is no reflection on him or on his staff but is criticism of Government policy and, while he is partly responsible for Government policy, I do not blame him for all the things that I consider are being done wrongly.
One of the biggest mistakes made is that, while the amount being spent on health services this year, £58,028,000, may appear to be colossal, an effort was not made—I made a similar remark in regard to social welfare a few weeks ago—to bring closer together the health services in this part of Ireland and in the Six Counties. It is really too bad that those who dislike us in the North can point to the fact that, if they come to Dublin and one of their children requires a health service, the cost is so great as compared with the Six Counties. We all know how the services are being paid for in the North but nevertheless, an effort should be made to bring the services closer. This is the first and the biggest criticism I have of the situation here.
The Minister has rightly pointed to the fact that choice of doctor for medical card holders will come into operation in most areas on 1st October, it already having come into operation in the eastern region on 1st April. I am afraid the enthusiasm with which many of us supported the choice of doctor scheme has been somewhat dampened by the overriding conditions which apply. For instance, there is a regulation that the doctor should be within seven miles of where the patient lives. This has resulted in many cases in a patient not having a choice of doctor. He may have a medical card but in a country district it is unusual to find more than one doctor within a radius of seven miles. The only choice in that case is of the doctor with whom the patient has been dissatisfied.
Deputy Donegan has rightly referred to the excellent service which many doctors gave under the dispensary system. There were, unfortunately, and are still, some doctors who believed that the dispensary service was there for the purpose of giving them a steady income while they operated a private service, supplemented by their income under the dispensary service. When it came to a choice of patients, those being paid for by the local authority got a lesser service than those paying hard cash. There were not many doctors who did this but there were some. Unfortunately, the position is that these people are left now without a choice if there is only one doctor within seven miles.
There is another thing which causes unnecessary annoyance, mainly because it has not been properly explained. If a person lives near the border of a region the doctor who has normally attended him, or two or three other doctors, may live in a town just beyond the region and because it has not been pointed out to some of these doctors that they have a right to be on a panel for patients in a region in which they do not live, some of them have not applied. There are areas where the position is satisfactory but there are other areas where, unfortunately, the doctors who live nearest the patients are not included on the list of doctors from whom people have the right to choose. In this case, the position is worse than it was before the system was introduced. I do not blame the Minister for this. Perhaps the fault lies with doctors who were not aware that their names could be included in the list and who, therefore, have been left out.
The Minister referred to the cost of hospitalisation. While the cost has increased enormously, it is true that all costs have increased and that money seems to be losing its value. We cannot blame the hospitals if they are unable to carry on on the amount of money they get and require extra money. A hospital which has not sufficient money cannot be operated properly. It is only right that hospitals should be provided with the necessary money to allow them to operate properly. Having said that, I feel that some hospitals are charging a great deal of money. I referred before to the case of a three year old child in a hospital in this city, in a supposedly private ward, in which there were four other patients for a period of about ten days, and for whom a charge of £80 was made.
The Department of Health should lay down maximum scales. If there are people who prefer to pay rather than to take advantage of free hospitalisation, they should not be robbed by some of these so-called private hospitals. Again, there are not many.
With regard to hospital charges generally, when the arrangement was made for the additional 15p on the social welfare insurance card to allow persons who had not a medical card to have free hospitalisation in public wards, both as in-patients and out-patients, a mistake was made either by the Department or by the health boards. In numerous cases patients who have been sent to hospitals other than the local county hospital are refused payment by the health boards on the ground that there was choice of hospital. In many cases the choice is made by the doctor and patients are being sent from my constituency to Dublin city because Dublin city was normally the area to which these patients were sent for special treatment. It is rather rough that people who are sent to places like this, even though they have paid 15p in insurance or are the wives or children of insurance contributors, should receive large hospital bills and be told that the bill cannot be paid for them on the ground that they have had choice of hospital. A patient can use only one hospital at a time. The charges are only as much, or in some cases, less than they would be if the patient had been in a hospital in the region. It is ridiculous in such circumstances that people should have to pay such hospital charges. If everybody insisted on going to a hospital within the region the waiting list there would be very much longer. We must be realistic. I would ask the Minister to look into this matter and to see if there is anything he can do to have the position regularised. It does not cost any more. It costs less than if they went to a hospital in the region.
Apparently we have some confusion about what out-patients are entitled to. If they pay 15p per week they should not find when they go to a hospital that certain things are not included in the list of out-patient treatment to which they are supposed to be entitled. Although the Minister told me by way of a reply to parliamentary questions that certain things were covered, in particular X-rays, I find that many patients still go to a hospital and are refused certain treatment and that they pay for it. It is hard enough for people to live otherwise without asking them to pay into social welfare insurance for hospital treatment and then to be asked to pay for things they require. I am afraid somebody is making a mistake and the Minister should clarify what people are entitled and what they are not entitled to. The Minister has been most helpful to me in replying to questions I have put down and I do not want to be putting down every query that comes to me in this respect.
The charge of 15p does not apply to those who have medical cards. But what is the situation about medical cards? Apparently arrangements are being made to try to have the issue of cards standardised in particular regions. In the region in which I live it has been decided that a single person with more than £10 a week is not entitled to a card, or a couple with £15 per week, an allowance of £1 being made for each child.
This is 1972 but the rates I have mentioned apply to ten years ago. No single person today with even an indifferent job would be earning £10 a week or less and no married man could attempt to live on £15 a week. Even the £1 per week for a child is not realistic. The system apparently does not take into consideration that many of those people have very heavy commitments. Take a married man with £20 per week. He pays £1 for insurance, leaving him £19. If he has only himself and his wife he will pay £2.50p income tax. That brings him down to £16.50p. He may have built a house and borrowed money to do so. Repayments will cost him another £5. Yet the State says he has to manage with £10 per week on which himself and his wife are supposed to live. He may have to travel to work. From my constituency people have to travel up to 50 miles to Dublin to work. They have to pay for a car.
Something has got to be done to relate people's incomes to their net take-home wages. There is the position that if they are in a rented house portion of the rent can be taken into consideration for the issue of a medical card. But if somebody either buys a house or borrows to build one he gets no benefit. It is unfair to say to him that he cannot have free medicine. He cannot eat the house. He has to live in it. People who try to help themselves and who by helping themselves are helping the State should not be so discouraged. It is something the Minister and the Department will have to consider.
Deputy Donegan referred to the situation in a number of hospitals. It will be many years before the regional hospitals we are talking about will be built. Some of them may be built in a relatively short time but most of them will not be built in our lifetime. There are buildings used as hospitals which do not deserve the name of hospitals. I have particularly in mind a hospital in the centre of Cavan town known as the Cavan Surgical Hospital. The nursing and non-nursing and medical staffs are of the highest order and the work they do has to be seen to be believed. I do not know how they do it considering the conditions they have to work in.
That hospital is understaffed. There is only one surgeon and he has to be on duty 24 hours a day seven days a week. The number of nurses is so small that if a serious accident occurs they all have to leave their wards. There is a serious fire hazard and the onus is on somebody to have something done about it.
The North Eastern Health Board have sent a subcommittee to visit that hospital and to examine it. All of their reports have been the same—that the hospital must be closed and the patients moved as quickly as possible. Where? The money is not there. As it is, if there was a serious fire there it would be impossible for anybody to escape from the top storey. This is not a scare story. In one of the non-nursing sections on the third floor where some of the girls sleep, the only method of escape is by way of bosun's chair—a rope with a seat on it in which they are supposed to swing out. In one of the wards there is a slide from one floor to another on which patients who cannot get out of bed are supposed to escape.
I am sure there are a number of buildings of that kind throughout the country. Before we start spending millions on regional hospitals we should concentrate our efforts on getting rid of these buildings and on providing accommodation for their staffs and patients. In regard to the Cavan Hospital, we asked for a report from the fire officer in Cavan but we did not get it. I understand the gentleman concerned has been transferred but we have not got a report from his successor. It is obvious that if this is allowed to continue there will be serious loss of life. Across the street 30 years ago a convent went on fire with tragic loss of life among the orphans who could not get out. Deputy L'Estrange uses the expression "standing idly by". We cannot afford to do that in this case.
It is unfair to the Minister and to the Department if these things are not brought to his notice. Here, however, they cannot say they are not aware of the conditions. I believe it would be possible to find alternative accommodation. Even temporary buildings could be put up and there is ample space for this. It should get priority.
The Minister referred to the rights of health boards and hospital authorities. I should like to know who chooses priorities in regard to money. Where will the money come from? It is useless talking about improvements until we know how much money we can get and spend and unless we are able to tell the Minister the money we require he will not be able to allocate the money.
There is another matter I want to clear up. First of all, I should like to thank the Minister personally in regard to the Navan County Infirmary. The top floor was in a very bad condition constituting a fire hazard. This is a very necessary hospital in County Meath which has been serving a very useful purpose. Unfortunately it ran into heavy debt. When it was established there were three trustees and a number of board members but gradually the trustees disappeared. After each local election Meath County Council have been appointing people to run the hospital, some being members of the council and others from outside. The local Catholic administrator and the local Protestant rector act as chairman and vice-chairman of the board.
When it ran into financial trouble it was difficult to find out who was responsible for running the hospital. Since the Meath County Council have been appointing the committee it would appear that these people would have some responsibility but, if that were so, it should have been taken over by the North Eastern Health Board. However, that was not done and there is some doubt as to who is responsible for the building. The co-operation between the North Eastern Health Board officials and the people who run the hospital is excellent and I should like to see it continuing. I am grateful to the Minister for his prompt action when it was brought to his notice that the hospital needed money quickly. A decision should be taken as to who is responsible for running the hospital. If it belongs to the health board it should be left to them; if it does not belong to them, we should be told who owns it. I should not like to see it falling into the hands of a private individual who might decide to close the hospital or use it for another purpose.
I should like to know from the Minister if he has made up his mind about what is to happen with regard to the sale of land at St. Davnet's Hospital, Monaghan. I appreciate that this is an awkward situation for the Minister. He represents the constituency of Monaghan and a matter like this arising on his own doorstep must be an acute embarrassment to him. However, knowing him as I do, I am sure he will make the correct decision no matter how it may affect his political future. I know that on two occasions the Minister has said that he considers it should remain the property of the health board, or if it is sold that the money should go to the health board.
I have stated that again, finally.
Then it appears the Minister has made a decision. A neighbouring county sold portion of its land before the transfer took place on 1st April and this has caused the annoyance. I am sure the Minister appreciates that. Unfortunately Deputy Donegan is not present now; I think he helped in that little deal. Cavan and Monaghan have been pouring in money and they consider they are entitled to benefit in this instance. Personally I did not think they had a right or, if they had, Meath County Council should have a right to the rich acres around St. Loman's Hospital at Mullingar. The ratepayers in County Meath have poured in a lot of money there during the years and we would like to get some of it back. Unfortunately, it appears we will not get any money.
With regard to people in receipt of social welfare benefits who are obliged to go into mental hospitals, it appears that during the years an arrangement was made that benefits payable to them are sent to the RMS of the hospital so that the money might be spent by the patients or on the patients. I should like the Minister to tell us in his reply what is the position with regard to this matter.
On two occasions patients complained to me that while they were in hospital they did not get the money; in fact, one patient complained she had been discharged and did not get her fare home. She was a mental patient and, therefore, she may have been slightly confused. Patients in mental hospitals may not be sure of what money they receive but I should like to know if there is an arrangement with regard to the disbursement of moneys sent to the RMS for mental hospital patients. I am aware that the RMS would be far too busy to deal personally with matters such as this; it is passed on to somebody else. In the case to which I have referred, the lady told me she received a cheque from the mental hospital for the amount of money she claimed she did not receive while in hospital. If there are 500 or 600 patients in receipt of social welfare benefits and if sums of £4 or £5 per week are paid on behalf of each patient, it comes to a substantial amount. I should like to be sure that it is disbursed in the way it was intended.
I was told of a case recently where a patient who was in receipt of a contributory old age pension had been in hospital for a few years. A relative told me that when she died the mental hospital board attempted to get possession of and sell a vested council cottage which the patient had held; this was despite the fact that each week her pension was sent to the hospital board. Matters like these cause some uneasiness. If this kind of situation is being dealt with properly I shall be satisfied, but I should like to be sure that there is not a breakdown somewhere along the line with regard to moneys which should go to patients. Patients in mental hospitals have enough to put up with without having problems like this thrust on them.
The Deputy may not be aware that there was a High Court decision against a health authority which sought money in such circumstances. The executor succeeded in the case I have in mind.
I am aware of that but the person to whom the Deputy is referring was not made a ward of court by the mental hospital board.
The individual in the case I have in mind was a ward of court. I was involved in the action.
People who work in hospitals are dedicated people. They have to carry out work not expected of people in other jobs; in mental hospitals the problem is quite considerable. I am not criticising the people who work in hospitals. I realise they are dedicated persons but I want to ensure that people in their care are not deprived of their entitlement, either through their own fault or for any other reason.
In a number of hospitals a problem has arisen in that it is difficult to find accommodation for medical staff. Some of the health boards have got round the problem by buying, renting or building houses close to the hospital in order to provide accommodation for the staff. I would suggest that the Department would recommend this policy, the implementation of which would be a capital investment. The non-nursing staff, as they are called, also do a very good job. We find that there is a furore if it is not possible to get sufficient medical staff but, unfortunately, it does not appear to be so important if the non-nursing staff is not up to the required number. The trade union with which I am associated have members employed in hospitals throughout the country and in some cases we find that the staff numbers are not maintained at the required level. In some hospitals, too, we find matrons who believe yet that there is not question of the right of notice to staff and are under the impression that if they do not like the way a particular person is doing his or her job that that person can be dismissed at an hour's notice. I understand that as a result of a Bill to be introduced shortly this practice will not be in operation very much longer. Most matrons are very good but there is still the odd martinet. Since they have decided to lead a dedicated life, they are under the impression that everybody else should do the same.
They were never asked.
I do not mean that. I would like to be fair to them. The conditions of work of ambulance drivers have not been good up to now and successive Minister for Health have made efforts to have the situation remedied but they seemed to go only so far and then let the matter drop. Somebody said once that one has to be born an ambulance driver in order to be able to carry out the work. These men are engaged not only in driving ambulances but they seem to be able to do work which even some doctors might shirk. They are on call at unreasonable hours. Although they work a normal day they find, in some counties, that after going off duty they are on what are known as first and second calls. Those on first call are required to remain at the hospitals while those on second call must remain in or near their houses so that they can be contacted if required. I wonder whether anybody in any other job in the country would agree, on completing a day's work, to be on call for a further eight hours and on going home to guarantee that they would not leave their homes. The matter has gone far enough and while every effort has been made to try to reach agreement somebody seems to be preventing a proper arrangement being made. I appeal to the Minister to make an effort to be generous to these people. A further conference in the matter is arranged for next week. Numerous conferences have taken place between the CEO's and the trade unions concerned but it does not appear as if much progress is being made. Regardless of increases in cost of living, there appears to be an idea that it is not necessary to increase the wages of ambulance drivers. It is ridiculous to suggest that, on a sevenday shift, they are in the same position as people who work a five day week from Monday to Friday. The matter should be settled now once and for all.
Regarding the trouble that arose some time ago in the mental hospitals, I was disappointed that after a strike had taken place following which a negotiated settlement had been put into operation, the Minister said publicly that he was dissatisfied with that settlement.
I am.
I agreed with much of what the Minister says but in this instance I disagree with him in expressing publicly his dissatisfaction with the agreement that has been reached as a result of negotiations. The settlement terms were agreed by both sides in the dispute and by the Minister. If the Minister was not satisfied he should have said so at the time. Perhaps he has his reasons for the dissatisfaction but I understand that the nature of the agreement reached was such as has been in operation in other services where it has been accepted as being excellent. The Department of Local Government, for example, are operating a similar system and, apparently, they find nothing wrong with it. The time to express dissatisfaction in matters of this kind is in the interim period and not when a strike situation is at hand.
I was glad to hear the Minister's suggestions regarding home help. The approach in this respect is enlightened and if it is taken advantage of by those who can operate it, it should be a great help. For a long time I have believed that the proper place to keep old people is either in their own homes or as near as possible to the neighbourhood where they have lived all their lives because that is where they will be happiest. There is a tendency in this country to push old folk out of the way so that the younger people can have a better fling. For a country which prides itself on its Christianity this is a black mark which it will be difficult to erase. I was glad to hear Deputy Donegan refer to the situation in St. Joseph's home in Trim. This is an excellent home but it is not big enough. There is a long waiting list for admissions and we hope that an effort will be made to have similar type buildings erected throughout the area.
In the short time remaining I should like to refer briefly to the tendency in some hospitals to unduly restrict visiting. While I agree that it is necessary that doctors in charge of patients should have the last word as to when visitors are allowed, it is ridiculous that any doctor should lay down that visiting on any day should be only between the hours of, say, 3 and 4 p.m., and that there be no evening visiting. That might be all right for those who used to be referred to as the "idle rich" but not for a working man who, on leaving work at 5.30 p.m. might have to cycle home and, having had a meal, cycle to the hospital to visit a member of his family.
Progress reported: Committee to sit again.