Committee on Finance. - Vote 48: Health.

I move:

That a supplementary sum not exceeding £10 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1974 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.

This is the first opportunity the House has had to debate a Health Estimate since the present Government took office. I propose in my opening statement to deal with the major developments in our health services which have taken place during the current year. I have already circulated to Deputies a statistical document which provides more detailed data on trends within the health service and which provides detailed information on developments in aspects of the service which I may not deal with today.

The original Estimate for 1973-74, as approved by the House, was for an amount of £92,557,000. It was necessary in February to seek approval for a Supplementary Estimate amounting to £7,891,000. This Supplementary Estimate was required to allow payment of increased prices and pay, to cover the cost of the 1973 budget improvements, to provide a further grant-in-aid for the Hospital Trust Fund, and to cover the cost of increased demand on our choice of doctor scheme.

In total, therefore, the Department of Health's Estimate for 1973-74 was for an amount of £100,448,000. This figure shows more than a 50 per cent increase on last year's Estimate of £66,493,000 and indicates clearly the commitment of this Government to improving our health services. The fact that the Health Estimate has increased by £34 million in the current year is no accident. The Government, before the last budget, took a deliberate decision to concentrate all available financial resources in the social policy areas. When this major increase in the Health Vote is added to the £60 million increase in social welfare expenditure, then the extent of the Government's commitment to our social services becomes apparent. The Government did what they had promised to do in the last budget. We began, in a very real way indeed, the task of bringing about radical changes and improvements in our overall social system and services.

I propose now to demonstrate in some detail the very real improvements brought about in our health services during the current year. I can do this most simply, I think, by showing the increases which have taken place in public current expenditure on our health services in the first instance and then translating those public expenditure figures back into actual Vote requirements to be approved by the House.

Public expenditure on our health services, exclusive of the £9 million provided by reducing the health element in local rate charges, increased in the current year by an estimated £27 million over 1972-73. This is a very major increase indeed and is, in fact, the largest single increase on health expenditure since the foundation of the State. Of this amount, £8,750,000 was spent on real improvements in both the scope and quality of our services, that is an improvement after allowance has been made for inflation. This means in effect that an 8 per cent real improvement in expenditure on our health services took place in the current year, again by far the biggest single improvement in real expenditure in the history of the State.

This radical improvement in real expenditure took place, I must emphasise, despite the fact that rising prices and pay added £18 million to health service costs in the current year, and despite the fact that £9 million will be spent in relieving rate charges this year also. I feel that this is an achievement the Government can feel justly proud of and one which amply demonstrates our commitment to fulfilling our pre-election promises.

I would like to spell out in some detail those areas of our health services where real improvements took place. Of the £8,750,000 spent on real improvements.

Approximately £5,400,000 will be spent in the current year on the provision of extra beds in our hospitals and other institutions, on the provision of additional health personnel, and on the additional cost of our general medical services scheme;

£740,000 will be spent on improving health boards' welfare payments; the easing of the means test for welfare payments will cost an estimated £1,575,000;

£500,000 is being spent on improving our community care services, especially the home help and social work services;

The creation of a new allowance for the domiciliary care of handicapped children will cost £450,000 in the current year;

An additional £40,000 is being spent on improving services for children.

All of these measures have led to real improvements in our health services. In addition, they show a reasonable balance between institutional and community care.

When the total additional public expenditure of £27 million is translated into actual Vote requirements and added to the amount for rates relief, the increase in the total Estimate for our health services is, as I said, in the beginning of my speech, £34 million. This has been a good beginning for the Government in the health field.

Before leaving the estimates in general, I should like to make two further points. The first of these refers to appropriations-in-aid of the Vote. This year appropriations-in-aid are estimated at £6,583,400. The two main sources of revenue under this heading are health contributions and payments to which this country is entitled under EEC regulations.

I expect that health contributions will yield £5 million in the current year. Most of this will be collected by the Department of Social Welfare and the Revenue Commissioners. The contributions of farmers are collected by health boards, at the usual rate of £7 per year, but I regret that despite this reasonable rate of contribution revenue from the farming community has been disappointing. I would remind all who are liable for the contribution that there is a statutory obligation to pay it and that those who fail to do so may have court proceedings instituted against them for recovery of the sum due.

In addition to revenue for health contributions this country is due £1,500,000 in the current year from the United Kingdom under EEC regulations. These regulations provide that the country where a person is insured for social security purposes is liable for the cost of health services for the insured person or for any of his dependants in another country.

The second point in relation to the estimates in general is that my Department have been considering for some time how the present system of financing the revenue deficits of certain voluntary hospitals and other institutions might be streamlined. The present system for the voluntary hospitals involves payment by health boards for in-patients and out-patients based on capitation rates and sessional fees and the subsequent making of grants from the Hospitals Trust Fund to cover revenue deficits which result from the disparity between capitation rates and actual costs for eligible patients. Expenditure by health boards in fulfilling this arrangement is recouped to the extent of 75 per cent from the Health Vote. Similarly, since sweepstakes' income is not sufficient to cover the revenue deficits of the voluntary hospitals, grants-in-aid of the Hospitals Trust Fund have also to be provided for in the Health Vote.

This system of meeting revenue deficits is obviously cumbersome in the extreme. Commencing in the next financial year it is proposed to make payments directly to the hospitals on behalf of health boards from the Vote for the Department of Health. This method will result in considerable saving in administration and other charges. The details of the new method have been worked out in consultation with health boards and voluntary hospitals and come into effect on the 1st April, 1974.

These then are some general comments on this year's health estimates. I should now like to deal with developments in a number of specific health policy areas and to indicate to the House my general thinking on these matters.

A matter of special concern to me is the provision for all parts of the country of a high quality general hospital service, adequately staffed and equipped. Investment of a high order will be necessary to achieve this objective and it is therefore essential to determine a rational programme of hospital development.

When I took up office in March last year I discovered that the previous Government had not reached the point where they had laid down a programme for future hospital development. The result was that capital investment in our hospital services was being held back quite simply because no one knew where this investment should take place. Obviously this state of affairs could not be allowed to continue indefinitely.

I was concerned to devise as quickly as possible a development plan for the whole country. The problems involved in devising such a plan are many and obvious. While the need for hospital reorganisation is seen by most people and by Deputies, there has been considerable controversy during the last few years about the possible location of major hospitals. In addition areas of low population density and difficult geographical features do not easily lend themselves to general solutions. Nevertheless planning is necessary. The general hospital services absorb half of the total annual health care expenditure and the cost of these services is rising rapidly. In the present year the estimated cost is £57 million. The needs of our patients, together with the requirement of cost effectiveness, require a rational plan for the future.

I took a number of steps during the year to help me devise such a plan. At my request Comhairle na nOspidéal drew up guidelines on minimum consultant staffing standards for general hospitals and on the population and catchment areas which should be served by hospitals conforming to these standards. Early in October I circulated these guidelines to the various health administrative bodies and asked them to form joint working groups for each health board area to work out the alternative solutions for their area which would conform with their guidelines. I asked the working groups to report their views back to the administrative bodies concerned, who would then furnish me with their views on the options for their areas.

I have now received the reports from the administrative bodies and am considering the options for development. The value of the consultation process which I have just described is that all health board areas in the country have had the opportunity to discuss the future of hospital development in their regional areas. Their advice will be invaluable to both the Government and myself when we come to make decisions.

The Dublin situation posed complex problems and was the subject of a special study by Comhairle na nOspidéal. They, with my agreement, set up two subcommittees to explore the options for north and south Dublin. The reports of the subcommittees were accepted by the comhairle and forwarded to me. For north Dublin, the comhairle recommended that there should be three major general hospitals, the Mater, Blanchardstown and a new hospital at Beaumont. The Mater and the new hospital at Beaumont would each have 500 to 600 beds, would provide a wide range of general and specialist services and work on a complementary basis.

In south Dublin three major general hospitals were also recommended: Saint Vincent's, Saint James's and a new hospital in the Newlands Cross area. Each of these would have 500 to 600 beds and provide a wide range of general and specialist services.

I have asked the Dublin Regional Hospital Board, the Eastern Health Board and the hospital authorities concerned for their views.

Devising a plan for future general hospital development is a time-consuming exercise. I have tried to involve as many health agencies as possible in free and open consultation on the matter while at the same time pressing ahead as quickly as possible to the point where decisions can be taken. Deputies will agree that the creation of a plan for hospital development is highly desirable, both from the point of view of providing a better service to patients and from the point of view of making the best possible use of scarce capital.

Public capital expenditure on hospitals in the financial year 1973-74 is expected to total about £9.0 million as compared with £3.6 million in 1970-71, £4.2 million in 1971-72 and £6.55 million in 1972-73. This figure represents a significant increase, in real terms, in the rate of capital investment in hospitals as compared with earlier years and is an indication of the Government's determination to improve, so far as our resources permit, the overall level of hospital services in the country.

A major part of the capital expenditure in the year under review relates to the improvement and extension of the accommodation and facilities available for the mentally handicapped, the aged and the mentally ill. A number of projects for reequipping and improving the general hospitals are completed though, for reasons which I have already outlined, major building projects in this field have necessarily been restricted pending decisions on the re-organisation and development of the general hospital services for the country as a whole.

The more important current hospital projects are as follows. In Cork, building commenced in January, 1973, on the new 600-bed regional hospital, and progress to date is satisfactory. The building of a gynaecological unit at Erinville Hospital has commenced, and a new nurses home has been completed at the Victoria Hospital. The Southern Health Board's revised proposals relating to the planning of a new 300-bed general hospital at Tralee are being examined in the Department.

In Limerick, the development of the regional hospital is proceeding by the provision of a 50-bed paediatric unit and a 50-bed psychiatric unit. Both these projects are at an advanced stage of planning. A new pathology laboratory is also to be built here and this scheme should be ready to go to contract this year.

At Galway Regional Hospital a new 50-bed psychiatric unit has just been completed, a new bio-chemistry laboratory is in course of construction and schemes for an intensive care unit and an extension to the X-ray unit are at tender stage. An additional 25 paediatric surgical beds are also being planned. At the nearby hospital of Merlin Park a second orthopaedic theatre and an extension to the X-ray department are at a very advanced planning stage.

In Donegal the tenders for a new 30-bed hospital have been obtained and building will commence shortly. In Wexford the building of a new maternity unit at Wexford County Hospital is now in progress and it has been agreed to increase the size of the unit from 22 beds to 60 beds. The building of a 50-bed geriatric unit at this hospital is also in progress. In Carlow the building of a new maternity hospital is progressing satisfactorily and should be completed this year.

In Dublin a number of improvements are in progress or in planning at the Mater Hospital. The building of a new cardio-vascular unit at the Mater has already commenced and other proposals in planning include an extension to the child guidance clinic and an extension to the X-ray department. The conversion of Drumcondra Hospital for use as a maternity hospital in association with the Rotunda Hospital is nearing completion. A major extension scheme is in planning for the Rotunda Hospital.

At St. James's Hospital, Dublin, improvements are in progress at Hospital 7 and a new central X-ray unit and child guidance clinic are being provided. Progress continues on the provision of suitable new accommodation for the aged chronic sick in replacement of old county homes. Major schemes completed in recent months include those at Castlebar, Sligo and Roscommon. At Tullamore a 100-bed geriatric unit has been provided at the county hospital.

Welfare home accommodation for aged social cases is now available at Kilrush, Clifden, Boyle and Carlow. Welfare homes at present under construction will become available at 12 other centres before the end of this year. Others are at tender stage or at an advanced stage of planning. Details of the hospital capital projects completed since 1st May, 1972, and projects under construction, at tender stage and at an advanced stage of planning as at 31st December, 1973, are contained in lists which have been circulated to Deputies.

I should like to discuss now some developments in our specific services which have taken place during the current year and to indicate policy areas where considerable groundwork has been done in preparation for major policy developments. The choice of doctor scheme was introduced in the Eastern Health Board Area in April, 1972, and in the rest of the country in October of that year. I am satisfied that the scheme is, in general, working reasonably satisfactorily at present and that it has lead to a significant improvement in the medical services provided to medical card holders. Approximately one million people are now covered by the scheme for free medical services and over 1,100 doctors participate in its operation. The scheme will cost approximately £12.3 million in the current year, or £2.4 million more than anticipated. This figure gives cause for some concern and every effort will be made to control increasing costs of operation in future years.

The visiting rate for doctors services in the year to 30th September, 1973, was 5.5 visits per eligible patient. The prescribing rate by pharmacists was 9.1 items per person, compared to a Northern Ireland rate of 7.0 items. Every effort must be made therefore to maintain reasonable visiting and prescribing rates in the coming year if costs are to be kept within reasonable bounds. A review of the scheme has begun this week with the medical organisations and the pharmacists. This will give each party the opportunity to ensure that financial resources are used as effectively as possible.

The scheme for assisting with the cost of drugs, which started to operate in every health board in October, 1972, is operated by the health boards in co-operation with local retail pharmacists for the limited eligibility group. To obtain assistance towards his drug and medical costs an eligible person simply sends a claim docket for each prescription dispensed together with a completed claim form for his total costs to his local health board. If the total cost is between £3 and £5 in a month he will be refunded half of the amount in excess of £3 and if it exceeds £5 a month he will be refunded £1 plus the full amount in excess of £5. This ensures that no person in the limited eligibility group need spend more than £4 a month on drugs and medicines. The scheme has been of considerable benefit to persons with limited eligibility and it will be extended to every insured person in the community from next April so that no family will have to spend more than £4 a month on their drugs and medicines.

There are two schemes in operation for persons suffering from certain long-term conditions. The first scheme provides for hospital inpatient and out-patient services to be provided free of charge for children under 16 years of age suffering from certain conditions. The second scheme provides for drugs and medicines to be made available free of charge to all persons, including adults, suffering from those long-term illnesses covered by the first scheme with the addition of epilepsy and diabetes. While representations have been received for the extension of the list to cover other conditions the extension of the assistance scheme towards the cost of drugs and medicines from next April will go a long way in ensuring that persons suffering from long-term illnesses need not have heavy expenditure on their medical expenses.

At present children who are found at pre-school or school health examination to require dental treatment and medical card holders and their dependants are eligible for dental services provided by health boards. The operation of these services depends mainly on the employment of whole-time dental officers employed by the health boards. Difficulties experienced by health boards in recruiting whole-time dental staff, coupled with the high incidence of dental decay, have made it impossible for health boards to provide a separate dental service for all those who are eligible. It is necessary for health boards therefore to accord priority to the dental needs of children and the service for adults is in the circumstances limited. However in the services for adults health boards are expected to give priority to expectant and nursing mothers and to persons who require dental treatment for urgent medical reasons.

According to latest information 155 dental officers are now employed in the public dental service. Despite recruitment difficulties this represents a substantial improvement, over 50 per cent, compared with the position some five years ago when important changes were made in the conditions of appointment of whole-time dental officers in order to make these posts more attractive. Also the removal of the marriage bar on the employment of women in the public service will, it is expected, have a beneficial effect on recruitment to the public dental service in future years.

It is the policy of the health boards gradually to expand their whole-time dental staff. A particular objective of this policy has been the appointment of senior dental officers, usually one for each county, to organise and supervise generally the operation of the health board dental services in the local areas assigned to them. The position has now been reached where a public dental officer has been appointed to each local area throughout the country, with the exception of the Carlow-Kilkenny area for which a senior post has been approved by my Department and which will be filled soon. Thus a basic structure has been provided in all areas on which an expanded dental service can be developed according as the available financial resources permit.

At present under the child health services dental services are confined to pupils of national schools and children attending child welfare clinics. It is not intended to extend the child dental service to other schools— though there is provision for this in the Health Act, 1970—until the services for national school children generally have been brought up to a reasonably satisfactory level. The Health Act, 1970, also provides for the making available of dental services by health boards to persons with limited eligibility. This provision has not been brought into effect as, so far, health boards have not been in a position to provide reasonably adequate services for even the categories of persons at present eligible for dental services. An extension of the health board dental services to persons with limited eligibility would inevitably mean engaging the private dentist to provide services for eligible persons on a fee per item basis as they do under the Department of Social Welfare's dental benefits scheme for insured workers. An expansion of dental services on these lines would not be feasible in present circumstances having regard to the extra costs involved and their priority in relation to the many other demands which are currently being made for improvements in the health services.

The current services I have described are on-going and developing over time. No significant new factors have arisen in relation to their operation during the current year although they are being kept under constant review. I have taken a special interest however in four other policy areas during the period and would like to indicate to Deputies the prospects for development in these specific areas during the next few years.

I am concerned that training and sheltered employment facilities for handicapped people are inadequate at present. Most of the work done in this field up to now has been done by voluntary bodies. While these have performed a very valuable role within the limits of the resources available to them, they have lacked real support and guidance from the State itself. The problem of training handicapped people and providing sheltered employment facilities should not be left to voluntary bodies to the extent that is now the case. The State has a very definite responsibility for these members of our community and one which it must seek to meet more fully in the future.

At present we do not have a national policy for training handicapped people for open or sheltered employment. Indeed policy in relation to overall services for handicapped people is limited and piecemeal as things now stand. I intend to look at the general question in the coming year, but I decided in last October that most immediate progress could be made on the question of training facilities and opportunities. I decided to set up an informal working group of experts to study the present situation and to make concrete proposals to me on the type, quality and extent of training services which were required in the short to medium term.

I expect to receive this group's report in the next few months. I will have it examined rapidly with a view to beginning as quickly as possible in the coming year the task of up-dating, improving and extending our existing services. I hope to define a national policy on the matter within the coming year—one which creates the maximum possible opportunities for handicapped people in the area of training and sheltered employment facilities.

The same sort of preparatory work is being done at present in relation to children's services. At present responsibility for administering these services is divided between a number of Departments of State—Education, Justice and Health primarily. This divided administrative situation is not conducive to good planning or good administration. It certainly does not lead to an integrated approach to the provision of services to children at risk or children in need of care.

I have been concerned about this situation for a considerable time now, as indeed have other Ministers. Unfortunately pressure of work in other services has prevented us from making much progress in this area to date. About six weeks ago however a small inter-departmental working group was set up to identify the key administrative, legal and services problems in the area of children's policy. This group has now identified the main problems under the headings I have mentioned and the Government will consider its report in the immediate future.

This Government are determined to set about reform in relation to children's services. Many children are getting an extremely raw deal in our society at present. I hope that reform will begin in the coming year and continue during the life of this Government.

While I am on the subject of children, I should like to speak at some length on the subject of our thalidomide children. The tragic story of these children attracted renewed public attention during the year as negotiations on compensation with the manufacturers in Germany and Britain, respectively, were approaching conclusion. It was the German-made product that was on sale in Ireland. In spite of, or perhaps because of, the widespread sympathy and controversy surrounding this subject, there has at times been some confusion about the facts and Deputies might therefore wish me briefly to outline the background and the present position.

Thalidomide, a sedative drug, was marketed in this country from May, 1959, to January, 1962, when it was withdrawn from sale by the manufacturers because it had come under suspicion in connection with the incidence of certain types of congenital deformities, mainly limb defects. The preparations on sale in this country were manufactured by Chemie Grunenthal of Germany, whereas in Britain the drug was manufactured and marketed under licence by the British firm of Distillers Ltd. The Irish children's claim is therefore against the German compensation fund, which is approximately the same size as that set up by Distillers. However as there are 2,500 children, including 34 Irish children, sharing the German compensation, the average available per child is considerably less than under the Distillers fund, as there are only 400 British children involved.

The law governing the administration of the German fund provides for capital payments of between £158 and £3,950 plus, in severe cases, monthly allowance for life of £16 to £70, the amount in each case to be decided in accordance with the severity of disablement. It is understood that over 50 per cent of the children will get the maximum rate of allowance.

It is the disparity in compensation between Irish and British children that has been the main complaint of the Irish parents and it is indeed a disappointing situation for them. However, I am afraid I have not been able to see that there is any prospect of getting a settlement for our children from the German fund equivalent to the British one. The Germans have pointed out that Irish children are sharing equally with their children in the German fund and that they did not see how they could give preferential treatment to Irish children as against their own nationals.

This being the position, the Government announced last May, shortly after taking office, that it had decided in principle to augment the awards to Irish thalidomide children and their parents from the German fund. I then established an expert Irish medical board, including a leading British authority on thalidomide, to provide me with a detailed picture of the degree of permanent incapacity and treatment and care required for each child. This will enable me to consider, in discharge of the Government's decision, in what way the special needs of the children can best be catered for. The board's findings are intended also to re-assure parents that all aspects of their children's disabilities have been taken into account by the medical assessors of the German fund. The establishment of the board was widely advertised and all persons in charge of children with disabilities which they thought might be attributable to thalidomide were invited to bring their children for examination. About 112 children came forward in response to this invitation and I am informed by the board that they consider that 34 Irish children have disabilities linked with thalidomide. The board are proceeding with the job of a detailed assessment of social and medical needs, both immediately and in the future, of those children whose disabilities, in its opinion, are attributable to thalidomide. This is necessarily a time consuming task.

For example it involves the admission of children to hospital for observation and a wide variety of specialist tests. It is important that this work should be done thoroughly and not rushed. I expect it to be completed by April.

I hope therefore I have helped to refute any suggestion that the Government have pushed the problem of these unfortunate children aside. Deputies will, I trust, understand that it is not possible to give effect to the Government's offer of further help until the detailed reports on the requirements of the children are to hand.

I might add that all Irish thalidomide children have been accepted as eligible, free of charge, for the full range of health services, including family doctor treatment, without regard to parents' means. Also, I have agreed to look sympathetically at details of expenses incurred by the parents in connection with their children's disabilities in the past, with a view to reimbursement of reasonable claims, either by health boards or in due course from the additional funds promised by the Government. A great deal of preparatory work has been done therefore in preparation for the Government's decision on the extent to which the German fund moneys should be augmented from the Exchequer. Again the Government will take decisions on this question in the coming year. I regret the delay on this matter, but in fact I had to start this process from the beginning and it is, the House will appreciate, a time consuming task and a task which must be performed carefully.

A considerable amount of preparatory work also has been carried through in relation to the development of our community care services. I need not emphasise to the House the vital importance of community care in our overall health policy. Prevention and care in the community are critical aspects of modern health policy and ones which help provide a better health service generally at less cost than would be the case if the major emphasis were on institutional services.

Two related problems must be tackled if we are to provide a good community care programme in this country. In the first place more specialist personnel will be required. These would include public health nurses, dentists, social workers and home help workers among others.

I have increased the number of social workers employed by the health boards from 74 to 120 in the past year. A great deal more remains to be done in this regard. I hope that the number of social workers with postgraduate training employed by health boards will increase rapidly in the next few years. I have also asked the health boards to start trainee schemes for social workers from October next and to continue to recruit qualified social worker personnel as a matter of urgency. The results to date have been dramatic in comparison with previous years, but a great deal more remains to be done before we can claim to have an adequate social work service in this country.

I have also increased the number of home helps employed by health boards during the past 12 months. Expenditure on the home help service increased from £150,000 in 1972-73 to almost £400,000 in the current year. As a result there are now approximately 1,400 home helps employed in the country and the number continues to rise. I have also asked health boards to employ and train home help organisers so that the service is placed on a sound footing for future development.

The number of public health nurses employed has increased by 39 to 834 in the current year and I have to expand this number still further next year. I also intend to increase the number of dentists employed by the health boards in our community.

In all the services I have mentioned it is my intention to increase numbers employed. These personnel all provide a valuable community health care service and one whose value is recognised by the communities in which they are involved. However as the personnel numbers increase it becomes increasingly important to create proper working relationships between the specialists concerned. There must be a co-ordinated team approach to community health care if the best possible service is to be provided.

This brings me to the second problem in community care—the problem of structures and correct working relationships between the personnel concerned. It is my intention that community care teams be set up in our local community. The task of each team will be to provide an integrated community health service under a team director. Discussions have taken place with the professions involved, with the health boards and within my Department on the working relationship of each team. I am frankly disappointed that we have not yet got the teams working. I intend during the next two months to make every possible effort to reach agreement in this question with the professional organisations concerned, because without their co-operation the concept cannot be turned into a reality.

As far as community care is concerned I am attempting to create a situation where highly qualified teams of health and welfare personnel are working in each community area. They should work as a team and they should be easily accessible and responsive to the needs of the people they serve. The idea is to create in each community a team capable of helping individuals with health or welfare problems which do not require institutional care and as a result to reduce the numbers receiving institutional care at present. The idea is to provide a preventive, supportive and rehabilitative service at a high level in each community. This is my goal and this is what I am working towards at present.

In regard to the psychiatric services, recent years have seen profound advances in psychiatric knowledge and methods, due in large part to therapeutic possibilities opened up by pharmaceutical discoveries. One of the most significant results of this new potential is that the treatment pattern nowadays in the service is one of out patient or short-term residential care backed up by support services in the community. As a corollary of this there has been a marked fall in the number of patients requiring long-term hospitalisation.

The impact of this new approach is amply illustrated by the dramatic fall in the numbers of patients receiving hospital treatment in our public psychiatric hospitals—from 20,046 in 1958 to 14,449 in 1973. This is a clear validation of the new approach and for my part I shall encourage health boards to press forward with the development of all aspects of community care.

Psychiatric units are now functioning at many of our general hospitals and are in planning for many others. While progress on this front is satisfactory, I should like to see health boards placing greater emphasis on the establishment of day hospitals and day centres and on the development of hostels. I am convinced that these types of unit have a very important role to fill, not alone in eliminating the need to admit many patients to hospital but also in contributing to the earlier discharge of patients to the community. Naturally the development of treatment structures outside hospital settings will prove of no avail if a sufficient pool of ancillary personnel is not made available. My Department are currently examining ways in which psychologists, social workers and other therapeutic personnel can be attracted in greater numbers to our expanding psychiatric services.

It might be opportune for me here to pay a well deserved tribute to the Irish public. For generations the approach to mental illness has been one of isolation and safe-custody. Almost overnight this was replaced by one of treatment in the home and in the community. This new approach, to be successful, demanded a willing acceptance of the new status of psychiatry by the population at large. I am happy to say that Irish people have responded in a most sympathetic way to the new approaches and have accepted the development of community treatment procedures in a most enlightened way. The emphasis upon community care does not mean that residential treatment facilities can be neglected. Indeed the need to upgrade residential facilities in many of our psychiatric hospitals is very apparent and this is an area into which I am channeling an increasing amount of funds.

There are also other areas of the psychiatric services which need to be developed. One of the most important of these is the services for children. Our main difficulty here is the world shortage of the highly specialised personnel involved but it can be taken that once these become available I will certainly provide the funds to develop this important branch of the service.

During the last year the need to improve accommodation and facilities generally at the Central Mental Hospital, Dundrum, has been receiving special attention. It is in this mental hospital that psychiatrically disturbed persons who have been before the courts are detained. It has been a matter of concern for some time that because of the limitations imposed by the out-of-date accommodation in the hospital it has been extremely difficult to carry out treatment programmes based on a modern approach towards the care of the disturbed offender. This is particularly regrettable in the case of young offenders who in a disturbed society tend to grow in numbers. They clearly require some special provision based on an enlightened approach towards their care.

A working party consisting of representatives of my Department, the Department of Justice and the Eastern Health Board has had a critical look at what can be done specially for the young offender at Dundrum. Members of the group visited centres in the United Kingdom and in a number of continental countries where a certain amount of experimentation in this field is being carried on. Based on their consideration of the most up-to-date thinking on the problem they have recommended the provision of a special 30-bed unit at Dundrum for young disturbed persons, male and female. While its primary purpose would be to treat young persons in detention the working party has recommended that it should also be used for other young persons who may be referred there other than through the courts. The treatment programme envisaged for the unit is based on the idea of a therapeutic community involving therapists drawn from various disciplines, with emphasis in selecting staff on youth and on social commitment.

During the current year the amount voted for health education and publicity was increased from £90,000 to £150,000.

The publicity campaign to discourage young people from smoking was continued. Television is the main vehicle for this campaign but many youth and sport magazines are also utilised. New leaflets and posters on other health topics were published and made available.

The on-going campaign to inform the public of facts of drug abuse was extended and 20 seminars were held throughout the country. Every post-primary school was given the opportunity of sending one or more teachers to these discussions. Seminars were also held for doctors, nurses and clergy and over 100 lectures were given to adults, mainly parent groups, to acquaint them with the facts of drug abuse. In addition a two-week intensive course on health education was conducted for 25 selected post-primary teachers during the summer vacation. All these courses and seminars also dealt with the problem of the socially accepted drugs, for example, alcohol and tobacco.

Deputies will recall that since I became Minister for Health I have given special attention to the all-pervading problem of alcoholism and excessive drinking. I accepted the report of the Irish National Council on Alcoholism relating to ways of combating this. I directed that a substantial part of the Department of Health's advertising budget should be allocated towards the promotion of an advertising campaign to inform people of the nature of alcoholism. This resulted in the Alcoholism Education Fortnight which was held last year and in the current "Sensible Drinking Makes Sense" television advertisements. I also requested health boards to increase their subvention to the Irish National Council on Alcoholism.

In order to achieve a concerted effort from Government Departments against this addiction I am in touch with other Ministers in order to explore ways in which the undesirable consequences of alcohol in Irish social and economic life can be abated.

However I am well aware that moral persuasion alone will not have such an impact if these are not backed up by adequate treatment facilities. My Department are currently engaged in reviewing existing institutional services for alcoholics in order to find out in what way they can be improved and rationalised.

I should now like to deal with some matters concerned with the administration and planning of our health services. While the content of services is obviously of vital importance it is important that we also create the right administrative structures and planning approaches within the overall context of health administration.

The health boards have been responsible for the local management of the health services since April, 1971. Their establishment marked a significant development in the administration of the services. It provided an opportunity to bring about a desirable devolution of authority and responsibility from the centre and this opportunity is being exploited.

It is, in my opinion, too early yet to come to any definitive judgment on the suitability of the health board structure. The boards' initial tasks were rendered more difficult by the necessarily slow build-up of experienced management teams. Despite this it would appear that a good working relationship has developed between the various interests on the boards and that they are receiving good support from their management teams while in turn giving them the necessary encouragement and freedom to get ahead with the job.

Already there are a number of positive developments which are encouraging indicators of the boards' performance. They have shown considerable aptitude in identifying and gaining agreement on major local needs and in reflecting these in their budgets. The process of agreeing and controlling the annual budget has steadily improved in each year since their inception, and during the past year each board have produced the first longer-term plans which will facilitate decision-making and resource allocation in the future. I would also refer to the co-operation which has been received from the boards in utilising the computer facilities made available by the Department of the Public Service, thus maximising the benefits of this major installation and contributing to the early development of an integrated health information system.

Comhairle na nOspidéal have been in operation since September, 1972. During that time they have effectively discharged their key function in deciding on the number and types of consultant appointments. They also submitted to me a report on the future development of general hospital services in the Dublin area. These recommendations included proposals for the future management of the Dublin hospitals. Certain of the key functions envisaged for the management bodies in relation to these hospitals are very similar to those which have already been allocated to the Dublin Regional Hospital Board. Consideration of the management proposals must inevitably include an assessment of the future role of the regional hospital boards. This conclusion is reinforced by the clear evidence that, under the aegis of Comhairle na nOspidéal, there is a readiness and indeed an anxiety among the various hospital interests to come together and propose agreed solutions aimed at achieving the objectives allocated to the regional hospital boards.

This matter will undoubtedly demand a lot of careful thought, particularly if somewhat similar proposals emerge from the studies now being conducted in relation to Cork and Limerick areas. Before coming to any decisions on this difficult issue I would of course seek the views of various interests concerned. I have no doubt that the members of the health administrative bodies would agree that the valuable time they so generously give should be utilised efficiently. I want to be satisfied that the structures through which their advice and guidance is obtained at all times ensures this.

Deputies will already have received a copy of the reportThe Separation of Policy and Execution dealing with the restructuring of my Department. The report examined how the Department might be restructured in order to give effect to one of the key recommendations in the report of the Public Services Organisation Review Group, namely, the separation of policy making and policy execution.

The Department of Health were one of four Departments selected to test on an experimental basis the implementation of this concept. The proposed clearcut division of policy and execution in relation to my Department represented a logical development of the trend which had emerged over the years. The Department have concentrated on policy formulation and the executive functions have mainly been discharged by bodies under their aegis.

The recommendations in this report have been accepted by the Government and are being implemented in co-operation with the Department of the Public Service. Many of the procedures involved are technical and detailed in nature but I am confident that the streamlining of the organisation will improve its capacity to plan and organise the provision of a better health service. I want to make it clear to Deputies that this reorganisation in no way curtails the Minister's powers, duties or responsibilities. In fact the overall objective of the exercise is to better assist the Minister to discharge his functions and to identify clearly those areas of the services calling for special attention.

The Consultative Council on General Medical Practice have submitted their report containing a number of recommendations, the adoption of which would have far-reaching consequences. For this reason the Government decided that it should be published thereby enabling the various interests involved to consider the report in depth.

This report is concerned with the future of the family doctor. It makes recommendations on vocational training and continuing education to ensure that the general practitioner will be able to provide the highest possible standard of care for the community. There is considerable emphasis on community service and there are recommendations on the relationship between the general practitioner and those involved in nursing and social care, proposing that these should form part of a practice team. The council favoured more active steps towards the creation and support of group practices which would facilitate the practice team concept. These were the priority recommendations. One item of major significance is the recommendation that eligibility for hospital services and general medical services should be the same. This is tantamount to recommending a comprehensive national health service. The extension of services on this scale is not a project which could be immediately considered in view of the cost, which would now be in excess of £30 million. The report has been published and is being considered by the various interests concerned before decisions are made. It will also have to be considered in detail by my own and other Departments.

I spoke in the House yesterday about the Government's decision to postpone the extension of limited eligibility health services to the entire population. This decision was taken because it has not been possible to reach agreement with the medical organisations on the method by which consultants would be paid in future for work done for public patients.

I deeply regret, as I said yesterday, the postponement. I had hoped to introduce free maintenance at least in public wards from April 1st in the belief that the consultants had no grounds on which they could object to such a proposal. When they indicated that they would not co-operate in implementing even this part of the scheme I had no option but to postpone the scheme. I could not risk a situation where people might be denied hospital services or where hospital waiting lists might be allowed to build up to serious levels. I cannot use brinkmanship tactics when people's health or even lives may be involved.

I intend, as I said yesterday, to set up a review body in the immediate future to recommend to me the rate and method of payment for consultants in the future in the context of the free hospital service. I intend to discuss the constitution of this body with the medical organisations and expect that the members of the body will proceed with their work with maximum speed. It is still the Government's firm intention to bring in the proposed scheme and within the shortest possible time.

I should like to take this opportunity of replying to some of the points made by Deputy O'Malley yesterday. He implied in no uncertain terms that the extension of the free hospital scheme would only benefit the rich. Is he really serious when he says that those who will benefit can be described as rich? Is he serious when he says that people over £1,600 per annum income or farmers over £60 valuation are all rich and therefore undeserving of free hospital care?

In fact most of those who will become eligible for free hospital care are far from rich or even well-off. I expect that a minimum of 300,000 people are at present not entitled to the free service. These include such groups in our society as gardaí, school teachers, members of the Defence Forces, civil servants, medium-sized shop-keepers, bank officials, insurance officials, local authority employees, together with their dependants and yesterday I was reminded that journalists could be included as well. Many of those employed in jobs such as those I have mentioned are not now entitled to free hospital care, but they certainly cannot be described as rich. For example approximately 27,000 teachers, 14,000 civil servants, 10,000 local authority employees, 10,000 farmers and 7,000 gardaí are outside the present limits for eligibility. If one takes into consideration the fact that the majority of these are married the figure can be multiplied by three or four. Are these rich? I do not think they are. Yet, Deputy O'Malley has helped to exclude these people from free hospital care for a further period of time. I hope he can justify his position. I would not like to try.

I regret that Deputy O'Malley chose to misinterpret my remarks yesterday on the question of free post-primary education. In fact I was complimenting the late Donogh O'Malley. I believe he took the right decision in introducing free post-primary education for all children regardless of the income of their parents. I am doing the same thing now in relation to free hospital care and the point I was making yesterday was that if Deputy O'Malley was consistent he would also have opposed the free education scheme. I take it he does not refute the free education decision now. Logically therefore he cannot refute the hospital scheme either.

He says I should have devoted the additional expenditure involved to other aspects of our health services, notably the general medical service. I have increased overall health expenditure in the current year by approximately £34 million. Of this increase a large proportion was devoted to improving our general medical service. The number of persons covered by medical cards has increased from 890,000 in March, 1973, to about one million now. I think these figures indicate that I have not been unconcerned about the need to improve our general medical services during my term of office. I have spread this year's additional expenditure across a wide range of health services. I see no good reason why some additional expenditure should not be devoted to abolishing a means test for hospital care.

There are a few points incidental to the delay in the commencement of this scheme to which I should like to refer specifically. First, there is the matter of the health contribution of 15p per week which, from 1st April, will be payable by all insured workers, that is, all persons working under a contract of employment. As it has not been possible to arrange that all insured workers and their dependants can from that date use the hospital services, it would clearly be right and just to exempt those who will be excluded from the liability to pay the health contribution. I intend to arrange for this by making special exemption regulations in relation to the machinery for collecting health contributions. However it would not be practical—certainly within the time available—to arrange for different rates of stamps to be used by employers for those employees who will be excluded from health services' eligibility. Therefore what I propose to arrange is that the employer will be asked not to deduct the 15p health contribution from such an employee but to bear the cost of it himself temporarily.

I intend to arrange through the Department of Social Welfare for the refund to employers of any such contributions borne by them. If an employer has made arrangements— through a computerised system, for example—whereby deductions of contributions for all employees are scheduled from 1st April, I will ask that the employer should arrange to see that employees excluded from the hospital services will receive a refund of the health contribution and in this case also the employers will of course be able to obtain a refund of the amount of contributions from the Department of Social Welfare. I know that these arrangements will cause some inconvenience for employers. I regret that it is necessary to cause this inconvenience but I hope that it will be accepted as unavoidable in the circumstances which have faced me.

A further point of difficulty could relate to some persons covered by voluntary health insurance. In recent months the Voluntary Health Insurance Board have in good faith advised persons renewing their policies to reduce their cover for maintenance on the understanding that subsidies from the health boards would be available to meet at least part of the cost of maintenance for all persons from 1st April. In the case of any person who has thus reduced his cover and who may not therefore be fully insured from 1st April I have asked the board to make arrangements so that any such person can readily get supplementary cover if he wishes to have it. The board have agreed to do this and I appreciate their co-operation in the matter. They will be issuing appropriate announcements about it shortly.

Finally, on this issue, I should make it clear that the scheme whereby assistance is given in the purchase of drugs and medicines exceeding in cost £3 in any month will become available to all insured workers and their dependants, without any income limit, from 1st April next. This service does not of course in any way affect the conditions of employment of consultants.

In making these detailed arrangements I have endeavoured to see that as far as possible the deferment of this scheme for some time will not cause undue hardship or inconvenience or impose unfair charges on any group of insured workers or other persons. I hope that thesead hoc arrangements need not be retained very long. They add too much complexity to already complex rules about eligibility for health services and the conditions for availing of health services. The sooner that we can sweep away these complexities on the basis of the scheme without any means test that I propose. the better it will be both for the public and for those administering and working in the service.

I move:

That the Vote be referred back for reconsideration.

We have had a long speech from the Minister, much of which was predictable. At least the parts which were not predictable were interesting. It is not often that in the presentation of an annual Estimates speech of a Minister two pages are devoted to the spokesman for the Opposition. I feel flattered by some of the things the Minister said——

I was just about to say the Deputy should feel flattered.

I was flattered by some of the things the Minister saw fit to say about me and I will deal in more detail with them later on. This is the first opportunity the House has had to discuss health since the present Government took office and the present Minister took over as Minister for Health from probably one of the most distinguished Ministers for Health this country has known. With the exception of the proposals which met a rather unfortunate and ignominious death here yesterday—the proposals for the extension of free hospitalisation—there has been no major new initiative on the part of the Government or the Minister in the 12 months or so they have been in office in so far as health generally is concerned.

They are, and I give them credit for it, pressing ahead with vigour on many of the schemes that the Minister's distinguished predecessor brought forward during the very fruitful years he was Minister for Health. I am glad this is happening and it will certainly have my encouragement that it should continue to happen. Because I have not had an opportunity in this House since I was appointed spokesman for health in the Opposition last July to speak generally on health, and since there has been no legislation on health and no Estimates on it before the House until today, normally I should like to speak on the subject at some length, but because the debate must be ended by 2.30 and because I know there are at least eight to ten Deputies on my side and presumably many more elsewhere who are extremely anxious to speak on this Estimate, I will confine my remarks to a period much shorter than I would normally wish to speak for. Unfortunately only a small fraction of those Deputies will be able to speak here today because of the unavailability of time and I hope the Government will see fit to put down the motion which we spoke about earlier today in the coming financial year so that an early opportunity will be given to the many Members on both sides who want to discuss health as thoroughly as it deserves to be discussed.

The end of the Minister's speech is as good a place as any to begin. That is the part in which I have been given the unique privilege of having a few pages devoted to me. It is not easy to make out just which part that is because I think a lot of midnight oil must have been burned last night in the Customs House in concocting this. On the top of the first of the pages devoted to Deputy O'Malley we have "39" and on the bottom we have it called "40". Then we go on to "40" and "41" on the same page, and then we have "41" and "42". Then we come to page "42" without any "43" on it. The chapter on Deputy O'Malley was clearly inserted last night by somebody who was presumably instructed to do it.

I am happy—I think it is only right because of the unusual approach of the Minister in inserting in the annual review of his Department the sort of statement he did—that I am able to discuss this now. The first thing that strikes me is that one would have thought the Minister would have learned his lesson yesterday. It appears he has not. The only real difference between what he said yesterday in his prepared statement which was typed out and distributed to Deputies and in his prepared statement today which was typed out and distributed to Deputies is that today he bitterly attacked Deputy O'Malley again but today he does not do what he did yesterday, attack the medical profession.

It was noteworthy that five of the nine pages of the Minister's speech given here at 4 p.m. yesterday were devoted to rather carping criticism of failure of the doctors to accept without question precisely what the Minister wanted them to accept. It does not greatly matter to me or to anybody else if I am attacked and therefore that attack is not of any great significance, but I imagine it does matter to the doctors if they are bitterly attacked in public in Parliament by the Tánaiste and Minister for Health. I do not know what their reaction will be—that is a matter entirely for them. At least we have to be thankful that they are not attacked today and that the midnight oil chapter added to this speech on pages 39 and 40 which is one page, and pages 40 and 41 which is another one page, and pages 41 and 42 which is another, and page 42, full stop, which is another, does not contain anything about the consultants.

The first point which the Minister makes is that I implied in no uncertain terms that the extension of the free hospital scheme would benefit only the rich. The Minister's statement asks:

Is he really serious when he says that those who will benefit can be described as rich?

The first thing I should do is to have a look at what I did say. It is contained in the amendment in my name to motion No. 7 on today's Order Paper:

To delete all words after "Dáil Éireann" and to insert the following:

"declines to approve the proposed Health Services (Limited Eligibility) Regulations, 1974 at this time on the grounds that:

(a) the proposals will lead to a dilution of existing services to the detriment of the less well-off members of the community;

I do not see anything wrong with that sentence nor do I see anything incorrect in the statement because it is widely accepted as inevitable that there must be a dilution of services and that it must be at the expense of the less-well off.

The second ground in my amendment is:

(b) benefit will accrue to the richest 10 per cent in the community only, at the expense of all taxpayers;

At no stage did I say these people were rich. Clearly they are not by any means. The Minister pointed out that people earning £1,600 per annum could not be described as rich. Of course they cannot, but what the Minister and the Government should do, precisely because these people cannot be described as rich, is to increase the income limit of £1,600 to a figure which would be the same in real terms today as that figure was when introduced in 1971. We are only too painfully aware of the inflation in recent years particularly in the last 12 months. It has been an inevitable consequence of that rampant inflation and constant increase in prices that incomes have had to rise at an abnormally fast rate of growth. It is perfectly clear that a man who was earning £1,600 in 1971 would be earning between £2,300 and £2,500 on average today. The duty of the Government is clear. They should not force these people into a position where they will not have free hospital services under the limited eligibility regulations, but they are forcing them into the position where they will have to pay for everything. These people should be entitled to the benefits of limited eligibility.

As I pointed out over a month ago, the duty of the Government is to sit down at a table with the doctors and say to them: "Gentlemen, there has been appalling inflation in recent years. Incomes have increased tremendously. There are people today earning £1,600 per annum who are not entitled to limited eligibility under our health services and they should be. We are proposing now to increase the income limit for limited eligibility from £1,600 to £2,400" or whatever the precise figure is which could be worked out on a statistical and economic basis. "Will you agree to that, because the number of people who are below £2,400 in 1974 is equal to the number who were below £1,600 in 1971?" If the Minister or his officials would sit at a table with the representatives of the medical organisations and put that proposition to them, I am sure they are reasonable enough to agree to such a proposition, if it is reasonably put to them in advance.

It is based on a means test. The Deputy sounds like a young Seán MacEntee.

The Labour Party are going through a lot of illnesses these days. What we see here today is merely one of the public symptoms. If the Government did what is clearly their duty to people in that income bracket, we would not have the Minister coming in here and asking me if people earning just over £1,600 a year are rich. Of course they are not rich. They are entitled to limited eligibility but because of the ideological carryon we have seen in recent months, they are now deprived of the eligibility under the health services to which they are entitled. This scheme has been put back for an indefinite time. It could be years before we see it. The Minister did not tell us yesterday or today. These unfortunate people who are caught in the bracket between £1,600 and £2,500 are forgotten about.

They are not.

They are told: "You will have to wait until this scheme has been worked out by a review board which will be set up. Then we will go back and talk to the consultants again." This might take years. At a Press conference last night the Minister was asked if it could be years before the scheme was introduced. He said he hoped it would not be. The implication seemed to be that there was a possibility that it might take years. We now have people who are most patently not rich, and it was never alleged by me that they were, who are being done out of the limited eligibility cover which would give them the free hospitalisation for 15p a week which they enjoyed in the past but which because of inflation, they have lost. They are being very unfairly treated. It is grotesque for the Minister to come in this morning and tell me that I tried to describe these people as rich. In fact, the very opposite is the case.

In the Minister's speech he listed all the people who have not got free hospital care at the moment. They constitute 300,000 people, or 10 per cent of the population. The number of people who are covered by the Voluntary Health Insurance Board is 530,000, that is, nearly twice the number who at the moment have not got limited eligibility or medical cards. Almost 20 per cent of the population are covered by the Voluntary Health Insurance Board although only 10 per cent of the population are not entitled to free hospitalisation. These figures should be carefully pondered upon.

The Minister goes on to say:

Deputy O'Malley has helped to exclude these people from free hospital care for a further period of time.

I am flattered to think that I have in some way contributed to any major decision by the Minister for Health. He made the decision. He dropped the scheme because he failed to negotiate with the medical profession before he announced it, and they were not prepared to work it until negotiations were completed. I cannot understand this statement:

Deputy O'Malley has helped to exclude these people from free hospital care for a further period of time.

Of course the Deputy has. He is fishing in troubled waters.

Deputy O'Malley must be allowed to make his contribution without interruption.

This statement which was made not in the heat of the moment across the floor of the House and without due consideration, but set out in black and white:

Deputy O'Malley has helped to exclude these people from free hospital care for a further period of time,

is ascribing to me extraordinary powers. I am flattered to think that I, directly or indirectly, seem to influence considerably the health policy of this State. I am grateful to the Minister for making this extremely flattering remark.

He spoke of post-primary education. This has been an unhappy field for the Coalition partners to delve into, not alone yesterday but for a number of years before. In his written speech the Minister said:

I regret that Deputy O'Malley chose to misinterpret my remarks——

In his oral speech he said to "interpret my remarks"——

—— in post primary education.

He goes on to say that he, the Minister, is doing for medicine exactly what the late Donogh O'Malley did for post-primary education. The comparison is ludicrous and totally invalid. What the Minister was attempting to do, and has now abandoned, was to introduce free hospitalisation in public wards for the 10 per cent of our population who did not already have it.

The late Donogh O'Malley in 1967 introduced free post-primary education in this country where there was none at all before that. There may have been an odd student here and there who, thanks to the courtesy and generosity of Orders like the Irish Christian Brothers and other teaching Orders of the Roman Catholic Church, may have enjoyed free post-primary education because of the inability of his parents to pay. That free education in so far as it existed for a very small number of people existed as an act of charity and not as a right. It was not given by the State to the very few people who, prior to 1967, had free post-primary education. It was an act of charity of the teaching Orders of the Roman Catholic Church. The late Donogh O'Malley gave every child of post-primary school age, if he or his parents choose to avail of it, the right to free post-primary education right through to leaving certificate.

Exactly what we are doing in regard to health without the income limit.

Deputy O'Malley must be allowed to make his statement without interruption.

I can only assume that the harrassed heckler whom I have on the opposite side of the House did not listen to me. I have spent the last three minutes explaining the difference between what the late Donogh O'Malley successfully did and what Deputy Corish, the Minister, is unsuccessfully attempting to do. The right to free education was given to 100 per cent of the children of Ireland by post-primary education. What is now proposed by the Minister is to give to the remaining 10 per cent of the population of Ireland that which 90 per cent of them already enjoy.

And they will have to pay for it. That is the distinction.

When the free post-primary education scheme was introduced the right was given to schools, if they so desired, to opt out of it. A number of them did so. I am not sure of the right percentage. It was not very great. It was about 5 per cent—perhaps a little higher in Dublin and a little lower in the rest of the country. They did not want to take part in it. For one reason or another they wanted to continue as fee-paying schools and they were perfectly entitled to do that. That scheme did not confer any benefit at all on the rich. Those who are well-off opted out of it. It conferred enormous benefits on the great bulk of the population of this country who are not well-off. There are tens of thousands of children in post-primary schools today who would not be at school at all but for that scheme. To compare that scheme, which benefitted the entire population and in particular the poorest people in the country, with the proposal of the Minister to bring in the top 10 per cent in terms of income and give them what the other 90 per cent already have is quite ludicrous.

I notice that my suggestion yesterday—and it was a Fianna Fáil suggestion—that whenever additional money becomes available in health matters it should more properly be devoted to an extension of the general medical services rather than to bringing more people into an already overburdened institutional service was rejected out of hand by the Minister on grounds of cost. That was also one of the recommendations of the consultative committee on general medical practice. At an earlier stage in his speech today the Minister rejected it out of hand again on the grounds of cost. The estimate of the cost of providing the choice of doctor scheme to all those with limited eligibility at the moment would be £30 million. Those with limited eligibility constitute about 60 per cent of the population of this country. They could get free general medical services for £30 million, but instead of that the Minister and the Government choose to spend approximately £20 million on extending free hospitalisation to the top 10 per cent. I know that the Minister's official estimate is £1.8 million. That is just one of the several ridiculous aspects of this whole scheme. If the 800 consultants in the country were to have an average salary of £8,000 per year the cost would be £6.4 million. That is before one penny is paid to the hospitals. It seems extraordinary that the cost of extending the general medical service choice of doctor scheme at £30 million should be rejected out of hand and yet that would benefit people who are very much less well-off than those we are talking about now. It would include those just above the income limit for medical cards. Instead about two-thirds of that sum should cheerfully be attempted to be spent in bringing in 300,000 people into the free hospital scheme. It seems to me that the priorities are all wrong.

The Minister should not be thinking about the comparatively small number who have no problem about family doctors or who for the most part have no problem about family doctors and who are covered by VHI at the top end of the scheme. He should be thinking about the large number of people in our community who are not in the top 10 per cent and who do not have medical cards and upon whom everything seems to fall. They pay for the family doctor service when they can afford to do so and they pay £7 per year or 15p per week, as is proposed for the very rich in the future. The great problem that is faced by those people is that because the limits for medical cards are so stringent and because the numbers who have them are limited to 30 to 35 per cent of the population there are a huge number of people in between who very often will not go to their family doctor when they should go to him, or who will only go to him at a stage in their illness when it is too late for him to be able to keep them out of hospital.

If the Minister were prepared to make a somewhat longer term investment than he is, and if he did not want the sort of ideological kudos of having, as he would put it, a comprehensive free hospital scheme, he would see that in the long-term the greatest dividends from the national point of view lie in the extension upwards to the millions of people between the top income bracket and the existing medical card holders of the right to participate in and have the benefit of the choice of doctor scheme.

The choice of doctor scheme for family medicine generally is but one aspect of community non-institutional care. That is something we on this side of the House have been giving a good deal of thought to in recent months. The more we study it and the more we think about it, the more we are convinced of the long-term value of community care generally to the people as a whole. I was glad to note that in his speech today the Minister devoted some time at least to the question of community care and to the increased recruitment of specialised officers and specialised personnel generally to help in the community care programme. He gave us some figures of increased recruitment in the past 12 months and told us he hopes there will be further increases in the coming 12 months. I heartily concur with that hope.

What disappointed me about what the Minister had to say on the question of community care generally was the fact that he spoke only of the amount of money it was hoped to spend and of the specialised personnel it was hoped to recruit. He did not devote any time of any significance to community care as a local effort, an effort by the people on behalf of the weaker members of the community locally. Perhaps because I come from Limerick I am conscious of what has been done and is being done and I know will be done by lay people to further the aims of the local community to support those who need help and support. It operates a little differently in Cork but it is at least as successful in Cork— some would say even more so. A great deal has also been done in the city of Kilkenny in relation to this. Many would think that these are probably the three leading examples of it in Ireland today.

It is a pity that, in what is otherwise a reasonably comprehensive review of the activities of the Department of Health over the past 12 months, less emphasis was placed on what has been done in the past couple of years than on what I hope will be done— and I hope that the Minister hopes too —in this respect by dedicated and generous lay people participating in councils such as the Social Service Centre in Limerick with trained professionals. That is the right mix. Enthusiastic amateurs on their own will never achieve that much, no matter how imbued they are with goodwill. There has to be a predominance of professionals in any such organisation and the direction must come from the professionals. That happens in Limerick and to a great extent it happens in Cork. That is the kind of thing the Minister should seek to encourage, not just in the cities where they were fortunate enough to have had, amongst others, Bishops who encouraged this development, but in every part of the country.

If you think in terms of pure economics only, the spending of a few pounds a week to keep an old person out of what used to be known as the county home is a tremendous investment not just in terms of pure cash for the State or the taxpayer, but much more importantly in terms of the happiness of that person himself or herself. To us on this side of the House that seems so self-evident that I often wonder why so much more is not being done now, and was not done in the past, to get these types of schemes off the ground properly. Indeed, very little was done up to about 1971 in this respect. It was only from then onwards that any impetus seemed to be given to the encouragement of local community associations to help people in their own communities.

In the past couple of weeks we saw an example of the opening of the new community centre in Limerick city into which, as far as I know, no public money of any kind went. The parish council of St. Mary's parish in Limerick paid for it entirely out of funds which they raised themselves. It is a splendid building, but it is not just the physical quality of the building which delights me but the fact that, in a city parish, in a city community, there is a building to which both young and old in that community can resort, where help can be and is given towards solving the problems and listening to the difficulties of both young and old. This was done by voluntary effort. Happily in Limerick there is a social service centre which will help to advise and direct the utilisation of that building and will help to provide the services which can be operated out of it for the local community.

I believe that can be done not just in Limerick but in similar parishes in other cities. While it is highly commendable that this has been done by voluntary effort, one cannot expect voluntary effort to be as successful everywhere else as it was in that instance. The Department of Health should actively encourage that type of development in every part of the country.

We are glad to see the tendency which started about three years ago towards building smaller welfare homes to which people who do not have anyone to look after them at home can go, people who are not so seriously ill that they should end up in what is potentially, at least, an acute hospital. We are conscious of the tremendous waste of hospital beds because of their use by old people who are in them not because they are ill or because they need acute constant medical treatment, but because they are old and have no-one to look after them. Basically they are in need not of medical care but of shelter, warmth and food.

With a properly organised local community effort, it would be in the most remote areas of this country only that it would be impossible to provide shelter, warmth and food for old people living alone. It behoves us all—and in particular the Minister for Health—to ensure that the organisation of local community efforts is such that, within the foreseeable future, that sort of support be provided for old people, in their own homes, in welfare homes or similar non-acute medical institutions close to their homes so that they can be maintained there at much less cost to the taxpayer and with much greater benefit to themselves.

There are a great many other topics I should like to discuss but because this debate is to end within two hours and because I know there are many behind me who wish to speak on it, I do not want to go on interminably. I want to return very briefly to the announcement made yesterday and referred to again today in relation to the proposed review body to look into the remuneration of consultants. I was rather taken aback yesterday when I heard this because I could not believe that yet another review body could be set up by the Government to review something else. One of the net practical effects of the establishment of this review body is that the negotiations which have gone on between the Department of Health and the medical organisations from the 10th January right up as far as, possibly, yesterday, are all now at an end, as it were. Whatever progress may have been made—and I understand some at least was made during those months—apparently that will be set aside now. The whole question of the remuneration of consultants will have to be examined by this review body. When, eventually—whenever it will be; I suppose no one knows when because the body has not been set up yet—but it could be a year or more— that review body brings out its recommendations on what should be the remuneration of consultants presumably—unless the consultants are prepared there and then to say yes to it, which one suspects at least would be unlikely—negotiations will have to start on the basis of the review body report between the medical organisations and the Department. Then we will be back to the position we were in on 10th January last.

The setting up of this body seems to me to suggest a sudden lack of urgency on the part of the Minister to have the problem solved and get the scheme off the ground. I cannot say I am heartbroken that he may be having second thoughts about it.

None whatever. The Deputy has not even seen the terms of the review body yet.

Has Deputy Desmond?

I am only going on what was said yesterday and today. It does seem to suggest that the Minister may be having second thoughts about some of what he proposed to do.

It is worthwhile drawing to the attention of the House the fact that when this review body reports the virtual certainty is that negotiations between the Department and the organisations will have to begin again. I cannot see the point of continuing negotiations while a review body sits on the very matters being negotiated.

One of a number of further matters to which I wanted to refer briefly is a question that has worried many Members of the House for some years past. It is the question of the abuse of drugs in recent years. While we were in Government and President Childers was Minister for Health, he was pressed, I would say, weekly, if not daily at times by a number of Deputies now on the Government side of the House with regard to bringing in up-to-date, comprehensive legislation on the abuse of drugs. The two principal people who pressed him were Deputies O'Connell and Byrne. We had an odd contribution from other quarters also; in fact, it was almost a constant repetition. I was involved to quite an extent in the drafting of that Bill because the Department of Justice had many views about many of the proposals of the Department of Health in relation to the Bill at the time. I had many discussions with the then Tánaiste about it. He introduced the Bill in the House and it got a First Reading in July, 1972. He circulated the Bill to Deputies on 4th January, 1973, having made an arrangement, I recall, with the Government Whip at the time that it be given a Second Reading the first week on which the Dáil would sit after the Christmas recess of that year. Of course, as we know, the Dáil was dissolved on the day before it was due to sit and the Bill was never taken. But the Bill was circulated, with an explanatory memorandum, on 4th January, 1973. That is 14½ months ago. A Bill was re-introduced, with a short title, the same as the old Bill. That was done shortly after this Government came into power. Notwithstanding the fact that a comprehensive Bill, on which an enormous amount of work had been done by the then Minister for Health, myself and the Departments of Health and Justice at the time, was readily available, ready for circulation the following morning if necessary because it has been printed and already circulated to Deputies, nothing has happened in that period of 14½ months.

All of us are aware that a situation which was serious 14½ months ago and about which we heard an inordinate amount from Deputies O'Connell and Byrne is even more serious today; that the drug problem is spreading and becoming more intense in this country. The types of drugs now being resorted to are even more damaging than those used commonly two or three years ago. It does seem to me extraordinary that nothing has been done by this Government in the time they have been in office to bring in that Bill or if for some reason I cannot fathom they do not want that Bill, another Bill. In the meantime it is fair to ask: how many young people have destroyed their lives because control over drugs in this country is inadequate at the moment and has been for some time? How many young people have literally, in many cases, destroyed their lives? How many are dead? And, of those who are not dead, how many are now physically and mentally in such a state that they will never be able to lead normal, full lives again?

On a point of order, I want to ask are we now discussing an Estimate for the Department of Justice or the Department of Health? Deputy O'Malley has been sermonising——

Deputy Coughlan, please.

And did his job very well.

Deputy Ahern, please. Up to now we have had an orderly debate devoid of interruption or disorder and the Chair wishes it to remain so.


Deputy Coughlan, I have made an appeal; please respond to it.

Why should I when the Deputy has gone off the rails?

That is a matter for the Chair.

This is a matter for Justice and not Health, and I know it, Sir.

If the Deputy persists, I will have to ask him to leave the House. The Chair will insist upon it.

The Minister for Health introduced the Misuse of Drugs Bill, which has the same short title and presumably long title, as the Bill introduced by his predecessor. He did that shortly after this Government came into office and we all assumed that within a reasonable period of, perhaps, one month or six weeks the Bill would be circulated and that it would be taken because of the great urgency of the problem. To my amazement almost 12 months passed and nothing was done. There was a Bill printed and everything else and I felt that it was my duty to put down the Misuse of Drugs Bill, 1974, which is precisely the Bill that President Childers circulated on 4th January, 1973. I hoped that, because there was for some reason a hold-up in the Minister's own Bill, I would get a First Reading for this Bill as a Private Member's Bill but unfortunately I have been refused that.

It has been the position of the Chair not to permit reference to existing legislation or the advocacy of new legislation on an Estimate of this kind. I have allowed the Deputy a reasonable amount of latitude but I feel that I must admonish him in that regard. The advocacy of new legislation is not in order.

Talk about the Littlejohns.

I have a list of other topics with which I would like to deal but I have spoken for almost an hour and it is scarcely fair to colleagues of mine, who only have until 2.30 to speak on this matter, to continue any longer. I regret that the debate is so short but I suppose nowadays we should be grateful that we are allowed a debate such as this at all.

Did you not take up the whole time with the Constituency Bill? Cast your eyes in your own direction and look into your own mirror.

Even if I felt justified in continuing to speak about the many topics that I would like to speak about I will clearly have considerable physical difficulty in uttering too many consecutive words from now on in the House because of the valued presence of my self-appointed adviser who has recently joined us.

You will be joining us soon and we will tell you what health is all about.

Deputy Coughlan, I wish to advise the House that this is a limited debate and must conclude before 2.30. The Chair is anxious that it be most orderly. Interruptions are out completely.

I will see——

Deputy Coughlan, if you cannot listen to Deputy O'Malley there is a way out. Will you please take that way out?

I will see that the truth is spoken.

The Deputy may speak if he can get in within the time limit but he may not come in here and disrupt the proceedings of the House.

I will not upset Deputy Coughlan by speaking any longer except to say that it is strange that usually when I make a contribution in the House these days we have Deputy Coughlan running in either at the beginning, or half way through or towards the end.

If you want to get personal I will give you personalities. Your record or that of anybody belonging to you will not stand any judgment. Mine will.

I am delighted that Deputy Coughlan is in good form this morning. I will now sit down and allow him the opportunity of expressing his views on this Department.

Take your beating.

I wish to deal——

On a point of order, is this Estimate only being discussed until 2.30 or will it come before the House again?

It will. This Estimate has to be passed today under the financial arrangements of the House. Of course, there will be future provision for continuation of the general Estimate debate.

I want to deal with the points made by Deputy O'Malley in relation to the Government's proposals to extend limited eligibility for the health services to the entire population on 1st April, 1974. Deputy O'Malley has advanced a number of grounds of opposition to this proposal. He has proposed five different reasons why it is not possible to do this. The first is that the proposals will lead to a dilution of the existing services to the detriment of the less well-off members of the community. That is a spurious assumption on the part of Deputy O'Malley. There is no evidence that in the event of limited eligibility being extended to the entire population there would automatically be a dilution of existing services to the detriment of the less well-off members of the community. To suggest that is a libel on the doctors who are currently administering the limited eligibility in part. It is certainly a naïve assumption that the Department of Health would allow that kind of situation to emerge.

Are you in contact with your people? With ordinary individuals?

Deputy Ahern, this is disorderly.

He knows this and I know that he knows it.

Deputy Ahern, if you cannot listen to the Deputy will you please leave the House?

You can take it that——

If the Deputy persists I shall order him out of the House.

I apologise to you, Sir, for anything I said.

Let that be the end of it.

It might.

I want to reject the first ground of opposition of the Fianna Fáil Party to the Government's policy in this regard, namely that our proposals would lead to a dilution of existing services and would be detrimental to the so-called less well-off sections of the community. This is very selective pleading from the Fianna Fáil Party. I trust their opposition is not the accumulation of implied threats by some consultants, a minority of consultants, who indicated they would dilute the services. I do not believe they would do so in the event of an extension of the services and the Fianna Fáil argument on this point is spurious.

The second argument by Fianna Fáil is that the benefits of a national comprehensive health service would accrue to the richest 10 per cent. They put down the words "10 per cent" on the Order Paper and they quoted it in statements. They said the benefits would accrue to this section only at the expense of all taxpayers. There we have a double-barrelled contradiction. The richest 10 per cent are taxpayers, as are many hundreds of thousands of lower paid workers. The Government put forward an argument that has total validity and can be sustained. Of course, the millionaires in the country should pay the national minimum health contributions to the State and they should be obliged to make their contribution towards minimum services. Whether they subsequently decide to avail of the national minimum health services is their privilege, as it is the privilege of the middle income group.

If the rich in our community—now the great area of concern of Fianna Fáil—want to have their private consultant, and their private rooms in private hospitals, of course they can have them. The Government will not take that privilege from them. If they want to pay through the nose for these services, of course they can do so, but the Government will not give them special exemption from making minimum contributions towards the national health services. This is a fundamental issue.

Fianna Fáil are in total conflict with the Government on this point.

Notwithstanding vested interests or propaganda, the Minister for Health is trying to lay a long-term sound foundation for the future health services of all the people. Fianna Fáil's opposition to the proposal is an endeavour to perpetuate class divisions in our community in a vital area of social policy. Nothing was more blatantly evident from the speech made by Deputy O'Malley.

I suggest that the opposition of Fianna Fáil to this proposal is poisonous and I use that word advisedly. It is poisonous in that it proposes the perpetuation of a two-tier health service, one for the medical cardholders and another special service for the rich who will have the privilege of making no contribution.

On a point of clarification, is the Deputy aware we will still have a two-tier system? Surely the medical cardholders will be on one tier in addition to the people with limited eligibility, even if it is extended. There will still be a two-tier system.

It is the ambition of the Government to break down the tiers developed during the years in the health service by Fianna Fáil. In preparing my contribution to this debate, I found it illuminating to go back over the submissions which I was a party to when I was in the Irish Congress of Trade Unions in the early 1960s, when Deputy Kyne and the then Deputy Michael Mullen were constrained to resign from the select committee on health. There is this ambivalence in Fianna Fáil in regard to this matter. Their attitude is that although they will look after the poor and the less well-off, will give them medical cards and general eligibility, the rich can have their special exemptions with special private consultants and special hospital facilities without being asked to contribute anything. That is the basic and fundamental contradiction in Fianna Fáil's approach.

As Deputy Nolan knows, it suits the consultants. It suits them to have the cream of their income from the cream of the land for their services. Does anyone know the salaries of consultants? With a few exceptions, information about their salaries, either before or after tax, is suspiciously difficult to obtain. This fact should be considered by Deputy O'Malley, the Fianna Fáil spokesman on health.

It is not my intention to exacerbate the current situation by being harsh or condemnatory but the attitude of Fianna Fáil in this difficult situation is to continue one service for medical cardholders and another service for those outside the income limits. This approach is divisive and is a blot on a political party who aim to be a so-called centre, popular, republican party.

It was evident from the contribution of Deputy O'Malley that in regard to the future development of health services Fianna Fáil have continued to drift to the right. Ever since they went into Opposition they have become a radically conservative party. They have gone away from the mixed economy to the free private enterprise system. On health services they are perpetuating class divisions.

I recommend as instructive reading to Deputy O'Malley the recently published second volume of Michael Foot's book on Aneurin Bevan, 1945-1960. The arguments put forward by the Deputy this morning are entirely reminiscent of the great debates that took place in 1948-49 in Britain when the Tories violently opposed extension of the national health service. After many delays and difficulties, finally the Minister succeeded in introducing an overall national health service and this is the aim of our National Coalition parties.

A further objection raised by Deputy O'Malley to the Government's proposals was that the voluntary health insurance scheme would be seriously affected. I challenge Deputy O'Malley to produce evidence to sustain that argument. I have not seen any statements from the VHI which suggest in any way that the scheme will be placed in a position of jeopardy as a result of the Government's proposals. I should like to pay tribute here to the VHI for its understanding and its co-operative approach in this matter. If we had the same co-operation from the consultants that we received from the VHI there would now be in operation the Government's scheme. The special pleading of Deputy O'Malley in relation to the VHI is quite naive. It is purely party political propaganda and it should not be supported by any responsible Member of this House.

Deputy O'Malley objected finally on the grounds that no agreement had been reached with the medical profession in regard to the proposals. That is self-evident. I can assure the House that this situation is not due to any lack of will on the part of the National Coalition. It is a strange commentary rather on the attitude adopted by the consultants that it was possible within a period of two to three months to negotiate a national wage agreement for three-quarters of a million Irish workers with a large number of trade unions involved while, apparently, the representatives of the consultants' organisations find themselves in an impossible position.

There can be such a thing as opposition to a Government proposal, not on grounds of salary or difficulty in negotiation, but on the ground of straightforward rejection of the concept of a national comprehensive health service. That is the nub of this issue. That is the basic problem, as they see it. For the past 15 years I have fought and advocated in the Labour Party and in public that all citizens, irrespective of means, are entitled to the best medical care and the best medical attention available without any question of income criteria applying to that availability. It is income criteria we propose to abolish in this National Coalition Government and no Fianna Fáil opposition and no other opposition to this ideological issue will deflect this Government from introducing a comprehensive national health service.

As far as we are concerned, it is the need for medical aid and not the means of the person requiring it should be the test of eligibility and it is time that politicians on both sides of this House woke up to the fundamental social principle involved. It is completely iniquitous that we should have in existence what one can only describe as a multi-tiered health service—the best for those who can afford to pay and, relatively speaking, second best for those who cannot afford to pay. To those who say there is no difference one has only got to be rich, with one's private room in a private hospital plus one's private consultant, to appreciate the big difference there is between what is available to those who are rich and what is available to those who are not.

It is National Coalition Government Policy that the wealthy, the half wealthy, the half rich and the very rich will all contribute on a minimum basis. If they want to avail of the services after that they can do so; and if they do not want to avail of them that is their privilege. But that does not give them the special exemption proposed here and ultimately it is our aim to have a national health service covering all persons. It is regrettable that Deputy O'Malley should fish in such very deep waters. They are dangerous and troubled waters and he may not get any thanks in the long term from those he is overtly supporting or from the sections of the community deprived of the benefits of the Government's proposals for a short period.

The reaction of the Fianna Fáil Party reminds me of the reaction of the Tory Party in Britain in 1948 in the historic debate on the introduction of the health services in Britain. Our Government will of course now be faced with no option, pending the completion of the negotiations, but to review the £1,600 income limit since inflationary factors are involved. That is a matter for the Minister and his advisers and I have no doubt that effective short-term arrangements will be made by the Minister in the best interests of the community and in the national interest too.

To put it colloquially, Deputy O'Malley has had his behind warmed for him this morning by the Minister when he discovered that the 10 per cent rich to whom he was referring were in fact school teachers, members of the Defence Forces, civil servants, gardaí and self-employed persons. For example, 10,000 local authority employees, 10,000 farmers and 7,000 gardaí are, all outside the present limits for eligibility.

I warn Deputy O'Malley he would want to exercise care in making allegations. He burned his fingers rather badly on a number of occasions in the recent junior doctors dispute. He should now read the terms of settlement in that dispute. Deputy O'Malley may think he has won a very small skirmish in the battle for a comprehensive national health service. He will certainly not win the battle in the long term.

The special highlighting by Deputy O'Malley of the medical card holders and the desire to extend greater eligibility beyond the current limits would take a great deal of examination. Anybody who has studied page 38 of the brief issued to Members of the Oireachtas in relation to the dispersal of medical cards throughout the country, particularly in relation to farmers, and who can see the widespread discrepancies between the different areas, will be able to gauge the lack of merit in Deputy O'Malley's proposal merely to extend the number of medical cards and the opposition to giving exemption to the top bracket in the community.

The more one examines the Fianna Fáil opposition to the Government's proposals the more one is reminded of the ludicrous situation that could arise whereby a Deputy would be liable to come into the House and suggest that those among the 5 per cent at the top who own the wealth of the community should not be included in the general income tax system. Perhaps we should jocosely suggest to Fianna Fáil that we might in deference to the top 5 per cent who own the wealth of the community exempt them from the income tax net. Therefore, there is an ideological gulf between the approach of Fianna Fáil and that of the National Coalition to the medical service.

I will do everything possible to ensure that the present negotiations, which I favour, will be brought to a speedy and generous conclusion. The Government have been extremely generous in regard to the junior doctors. However I do not think that is the issue here. The fundamental issue is the extension of the health services as quickly as possible on a national basis. It is here that Fianna Fáil and the National Coalition part company in no uncertain manner.

I recall 1972 when the then Fianna Fáil Government ensured participation of private medical practitioners and retail pharmacists in the new services. The then Minister for Health, Deputy Childers, pointed to that as being a noteworthy landmark in our health services which would remove any discrimination in the matter of providing family doctor services. The point might be made that as a result of that effort, 20 solid years of policy proclaimed by the Labour Party and by the trade union movement had been put into effect. I recall the utterly reactionary attitude of the former Minister, Seán MacEntee, in this House and I remember appearing before the Select Committee on Health Services in the 1950s from which the Labour Party resigned in frustration.

This morning Deputy O'Malley followed in Seán MacEntee's footsteps. He displayed no imagination and did not want any national extension, rather that the special professional groups in the medical service should be allowed their special privileged position, buttressed no doubt by Fianna Fáil's opposition to the Government in this matter. This will not be successful in the long run. We have had the proposals of the Government and there will be no drawing back from them.

The arrangements which have now been made, I can assure the House, are interim. The fundamental plan of policy has been decided by Government decision. It has national support. It has the support of the ICTU, long the advocate of decent health services in this country. It has the full support of all the parties comprising the Government. On that basis, whether now, in two months, in six months or within the year, it will come into operation.

There are a few additional comments I wish to make on the Minister's speech today. First of all I congratulate those on the National Social Services Council on their publication of the information bulletin. The Council have been most helpful and most effective in publishing information on social workers, Deputies and others engaged in the medical and social services. I commend them for what they are doing. I congratulate them also on the tremendous efforts they made recently to set up a major conference, the first in the history of the State, for discussion of the concept and the role of citizens' advice bureaux. Deputy Wyse, who has presided jointly with me over that conference, will agree it was a useful exercise by the National Social Services Council on which he sits as a council member.

I should like to see CAB introduced on a voluntary basis, supported by the State and operating on a nonpolitical and non-sectarian footing. I have no doubt the Minister for Health will give considerable assistance and recognise the new role in the future of the citizens' advice bureaux when we come to establish them. They could more appropriately be called "community information and advisory centres".

The Minister expressed concern in relation to the choice of doctor scheme, about the magnitude of the cost of that scheme in the current year. In my view there should be a very close examination of its cost. It will cost approximately £12.3 million in the current year, £2.4 million more than anticipated. It is a cause for some concern. I can understand the very serious misgivings of the Department in relation to the fee per item of service.

If one deducts from the figure of £12.3 million something in the region of £7 million in respect of drugs, one is left with about £5½ million to be shared between 1,100 doctors. That gives an average of about £4,000 per annum. I am sure within that range there is a wide discrepancy in terms of income levels. Bearing in mind that many doctors are not exclusively devoted to the choice of doctor scheme, if a doctor gets an average of £4,000 from the scheme plus a similar amount from private practice, he would have a good income. Of course, I am speculating. A close examination of the figures of the various health boards would throw up rather illuminating data in relation to the choice of doctor scheme.

I agree with the Minister that the revenue from the farming community, despite the very reasonable rate of the 15p per week or £7 per annum contribution, has been disappointing. This is an area which we should examine again. Who pays for the health services? I am dubious that many farmers are paying the £7 per annum. I understand there are enormous difficulties in trying to collect these contributions. A very large number of people living in the farming community get the full benefit. Contributions from industrial workers are stopped from their pay cheques. The Department, in consultation with the Revenue Commissioners, may have to devise a more effective system of collecting contributions. I would not have any sympathy for anybody who did not pay this very small contribution. This rate has been fixed at £7 for the past three years. When one remembers that inflation over that period rose by 30 per cent, one will realise that, relatively speaking, £7 is very little indeed.

I have received a number of complaints from medical card holders about the choice of doctor scheme. In my constituency of Dún Laoghaire a medical card holder in his late 70s went to the outpatient's department of St. Vincent's Hospital and received a prescription from the specialist. He then went back to his local doctor and checked and reentered it. Then the patient went to the pharmacist to have the prescription filled. That is not a national health service. It is not fair to those in the community who are in greatest need, that is, medical card holders many of whom are old people.

I should like to refer to the thorny subject of contraception. In the long-term and under the auspices of the Department of Health and the health boards, family planning advice centres should be made available, particularly for married persons. There has been a great deal of emotional propaganda and rather disturbing public debate on this topic. Many doctors are providing this service already but there should be provision made for it in a more formal sense.

I should like to discuss the problem of alcoholism. This in a sense is analogous to contraception because it shows the moral laws in our society. We hear a great deal about the contraceptive mentality. Many hundreds of thousands of documents will be distributed in the next few days explaining the disastrous effect of this mentality on our community. Those who are expending such energy in promoting the public understanding of their interpretation of the contraceptive mentality would be doing far more social good if they dealt with the more serious moral norm, namely, the alcoholic mentality. There is in Ireland, as in every other country, an alcoholic mentality. That mentality has caused far greater damage to persons of all ages and to both sexes than the contraceptive mentality.

It is very strange that few people are prepared to admit that alcohol has caused more marital breakdowns than contraceptives. Alcoholism is the cause of far more industrial absenteeism and loss of national production than contraceptives. Alcohol has resulted in four out of ten motor accidents in which people were maimed or killed. Those who are contemplating the issuing of literature dealing with the contraceptive mentality could add a footnote of admonition in relation to a few other mentalities.

The most pervasive mentality in Ireland is the property mentality but that is outside the scope of this debate. The second most pervasive one is the money mentality but certainly the alcoholic mentality is one which is of grave national concern. There are more desolate and abandoned children in our community, more deserted wives and husbands, because of alcoholism than would occur in a thousand years from the so-called obsession which some commentators have with the contraceptive mentality. This needs to be put in the proper prospective.

I fully support the Minister for Health in giving special attention to the appalling problem of alcoholism in our community. I would encourage the Department to support this view.

I am very pleased to see the Minister's reference to children's services. We can thank the National Coalition Government that, for the first time in decades of ministerial Estimate speeches, there is a section on children's services this time. As a Government backbencher I wish to say that I am not at all satisfied about what I would regard as areas of education administration. As far as I am concerned—I would exclude the Ministers particularly—the hierarchy among the staffs of the Departments of Education and Justice should wake up rapidly to the fact that there is a growing volume of irate opinion among Government backbenchers who feel that these people do not want the scheme or do not exercise sufficient imagination in looking for integrated child care and preventive services in our community.

I do not think that the strong area of public opinion, which I regard myself as being part of, will tolerate a situation in which responsibility for administering such services is divided up in a hotch-potch way between the Departments of Education, Justice and Health and to a certain extent Social Welfare. I am aware of the fact that the Minister and the Parliamentary Secretary, Deputy Cluskey, hold strong views on this matter. They can be assured of support from Government backbenchers for an integrated approach to the services for children at risk and in need of urgent care in our community.

I would remind those who are displaying such preoccupation with the contraceptive mentality to display some further energy in writing to the politicians and the Government in support of the Minister's statement that many children are getting an extremely raw deal in our society at present. I agree with that and I welcome the setting up of the small interdepartmental working group. I congratulate them on identifying the key administrative and service problems in this area. They can be assured of full Government support.

I urge the Parliamentary Secretary to the Minister for Education to rethink some of the attitudes which may have been adopted in this area. I would urge the Minister for Justice not to go along necessarily with internal departmental views in his Department. I am putting these views on the record. They are my personal views following statements made by Ministers and Government spokesmen. Somebody must express such views. The Minister and the Parliamentary Secretary should press ahead in this area. They will have the support of all interested Government backbenchers.

These are my comments in relation to the Estimate. I regret that I have had to curtail my contribution because of the desire of the Opposition to contribute again. We had agreed that we would speak briefly this morning. A great many things have happened in the Department in terms of policy, administration, internal form and the Devlin Report. The last White Paper on health services was published in 1966. As soon as the negotiations are completed with the consultants it might be opportune for the Government to lay a further White Paper in regard to the further extension of the health services before each House of the Oireachtas.

I wish the Minister well in his negotiations with the medical profession. The medical profession will find the Government generous in their approach. They will find that the Government are not seeking any form of confrontation unless they are mischeviously forced into that kind of totally undesirable situation. There is nobody in the Government who has a more conciliatory, generous or open approach than the Minister for Health or who is less anxious for confrontation in terms of character and political attitudes than he is. The consultants are very fortunate in having a Minister for Health who will not attempt to push them into a corner. I also know that if the Minister for Health is put into a corner the persons who attempt to do so will find that they, in fact, are in the corner themselves and they will have to work their way out of it. That is something which would be very desirable. I hope that the review body will be set up immediately and their terms of reference agreed upon. I hope that they will get down to their work and that we will have a service in operation as a matter of utmost urgency.

As already stated, this is the first Estimate presented to this House by the Minister for Health since the National Coalition Government took office. I wish to congratulate the Minister on his brief, which is a very comprehensive one. It is a pity that we have not got sufficient time to discuss all aspects of his statement. The health services affect the whole community. There are many people in this House who are capable and who have experience, and who would be only too delighted to make a contribution and help the Minister in the administration of the different services for which he is responsible. Quite a number of people are anxious to make a contribution and I can touch only briefly on a number of aspects of the Minister's statement.

One matter which comes to mind immediately is the dental service. The dental care service has not improved over the past 12 months. It is important for the Minister to remember that the more people we bring in under the health services the more the demand is for professional personnel. The dental service is practically static because we are trying to bring more people in under it and we are not providing additional personnel. When a service is being introduced or broadened, a proper assessment must be made of it to prevent hardship and disappointment. I am not saying that I am not aware of the Minister's difficulty in recruiting dental personnel but more positive action must now be taken to improve this important service.

I was somewhat surprised that we did not get any information from the Minister on the effects of fluoridation. Some years ago the local authorities were asked to introduce fluoride into water and many people throughout the country opposed this. I believe that fluoridation was a step forward. I have no doubt that if statistics were prepared it would be proved to have been a worthwhile exercise. I understand that fluoridation becomes effective after ten years. The Department of Health should now be in a position to give us some idea of the value of fluoridation.

The Minister also mentioned health education and publicity. Our television network is being used for all kinds of publicity and gimmicks. There is no question about that. It is a pity that health education is being neglected from the point of view of publicity. We all know there is excessive drinking by our young people. We all know that they are entering publichouses and that the people behind the counters know they are under the legal age at which the taking of alcohol is permitted. This brings us back to a very important aspect of health education, publicity. Television is really effective in this regard.

There is also the problem of drugs. We know that innocent boys and girls are haunting places where there are drug peddlars. It is about time that somebody in RTE prepared a weekly or a monthly programme on some aspects of health education publicity. The people are paying for television and they expect some definite benefits from it.

Health is wealth and people do not complain about money spent on health. It is important that people should get value for their money. It is also important that we should continue to aim at perfection in our health services. I am glad the Minister placed so much emphasis on community care services. Community welfare is essentially a shared responsibility. The necessity for a partnership between voluntary and statutory bodies is now accepted as a fact of life if the needs of the community are to be effectively identified and met. For many years we in Fianna Fáil have been conscious and appreciative of the considerable amount of voluntary work undertaken throughout the country by social service community councils. We are convinced that these councils have a key role to play in ensuring that proper use is made of the resources at the disposal of the community by voluntary workers.

When did this sunshine dawn on the Fianna Fáil Party? I was present when one Fianna Fáil Minister, Mr. MacEntee, openly declared war on the voluntary institutions. He was taken to task publicly by the Press in Limerick for his statement about voluntary institutions.

The Deputy will have an opportunity to make his own contribution.

Deputy Coughlan came in here——

I came in here to tell the truth.

——not very long ago and made an attack on his own colleague in Limerick.

I did not. I was putting him on the line and I will put Fianna Fáil on the line. I will expose them for what they are. I will keep them on the line.

Deputy Coughlan should conduct himself.

If the Deputy has something to offer on this very important debate I will sit down and I can assure him that I will not interrupt him.

Deputies have only 40 minutes.

I will answer the Deputy about Fianna Fáil policy.

On voluntary institutions.

Deputy Coughlan should keep quiet. He might not be there very much longer if Lipper has his way.

Deputy Wyse without interruption.

Deputy Coughlan said something which must be answered. I am afraid he is not reading any policy published by Fianna Fáil.

They change it from day to day.

I want to enlighten——

The republican party is gone anyway.

What did the Deputy say about the republican party?

I will answer Deputy Coughlan.

That is what I want.

I was mentioning the community care policy. The former Minister for Health——

Which of them? Name him.

Would Deputy Coughlan allow Deputy Wyse to continue? There is a very limited time available to Deputies who wish to contribute.

They are playing time out.

Deputy Wyse has only commenced.

The former Minister for Health, who now holds the very high office of President, introduced something to which tribute was paid a while ago by Deputy Barry Desmond —that was the establishment of the National Council for Community Services. I am afraid Deputy Coughlan is not aware of its existence. For his information, it was established here in Dublin, made up of representatives of people throughout the country involved in community work.

I want to inform the Deputy that I have been 25 years a member of a public health authority.

Deputy Coughlan will have an opportunity later.


Deputy Pearse Wyse without interruption.


Would Deputies allow Deputy Wyse to continue? What they are doing is curtailing the opportunity of Deputies to contribute.

I was talking about community services. I want now to touch briefly on one aspect of them. In the past substantial sums of money were spent on the erection and renovation of geriatric and psychiatric institutions. At that time I felt, and still believe, that that money should have been spent in keeping people out of institutions. I was glad to read recently a speech of the Minister placing emphasis on the care of the aged. If we look at our services for the care of the aged, we will find quite a number of anomalies. I understand— and I hope I will not be contradicted in this respect—that in the whole country there are four geriatricians: one in Cork and three in Dublin. Being a member of the Southern Health Board I want to place on record my compliments and indeed congratulations to the wonderful work done by Dr. Hyland in St. Finbarr's Hospital in Cork. It is important that I state here that I am not saying for a moment that our institutions should not be upgraded and that all hospital facilities and comforts are available in our institutions. I am trying to direct the attention of the Minister to this very important service of keeping old people in their own homes. This can be done and we have proof of it throughout the whole country where community services operate. But it can be achieved only by placing the proper back-up services behind the voluntary organisations, such as the public health nurse who calls on the old person, and does medical dressing, the social worker, the meals on wheels and the doctor. We will be hearing more and more about this in the future. In Cork there is a tremendous turnover of old people going to hospital, being attended to medically and then being discharged into the care of the community.

Home help is most essential, but there is one aspect of it to which I should like to direct the Minister's attention. I understand, as a member of the Southern Health Board, that we give home help—and keep the old person out of hospital—to people other than relatives of the person concerned. To my mind this is totally wrong. Irrespective of whoever they are, they are fulfilling an important obligation. If a daughter who may not have social welfare contributions and may have dedicated practically all her life to her home has to come in now under a category called "home assistance", she is not entitled to home help. I know the Parliamentary Secretary is very keen on this type of work. I would ask him to investigate this and try to give a little more than is being given at present to those people who dedicate themselves to old parents or to an old relative.

I am very enthusiastic about the geriatricians because I feel this is the key to the care of the aged. I would ask the Parliamentary Secretary to convey to the Minister our concern for the employment of more geriatricians in geriatric institutions throughout the country. I believe too that we should take a further look at the whole question of psychiatric services. I believe the general public must be brought closer to the work of the medical people concerned here. I think people are becoming more and more educated in this field. But the unfortunate thing about it is that our after-care services are appalling. A person will undergo treatment in a geriatric unit, perhaps for three or six months. They are then discharged but, unfortunately, return to the environment which may have been the cause of their trouble originally. It would be a good exercise if we could prepare statistics on this—people coming in for treatment, being discharged and, within six months, coming back again to the institution. This is due mainly to the fact that we have a very poor after-care service. I have many reasons to believe this.

As I said, I am merely touching briefly on a number of matters. But I want to say a word—and I may not be in order in this—about child adoption which comes partly under the aegis of the Minister for Health. I would ask him to have discussions with his colleague, the Minister for Justice, to examine this human problem. There is much hardship and heartbreak in this area. I have no doubt but that a more suitable approach could be devised so far as the law of adoption is concerned. I do not think there is a Deputy in the House who has not come up against this type of hardship and I think a revision of the law on adoption is long overdue. I would not like to anticipate the changes here because hardship can be created for both the mother and the people adopting the child. Certainly the time has come when we must review this situation.

Has the Deputy any suggestions?

I am sure I have better suggestions than the Deputy. He comes in here and interrupts instead of making a contribution.

I should like to refer briefly to the physically handicapped. I have no doubt that the Minister is trying to do everything in his power to alleviate hardship here. Recently I tabled a question asking the Minister to make available to physically handicapped people living alone free electricity and free TV. The Minister told me that he did not have statistics available to him regarding the number of people involved. A week or a fortnight later I tabled another question asking for the number of people living alone who are physically handicapped. The Parliamentary Secretary answered that the number was 5,000. The income of a physically handicapped person living alone is very limited and the rising cost of electricity and television is inflicting hardship. I would ask the Parliamentary Secretary to have this examined. I do not think it would cost the State very much money. I have visited the homes of such people and seen the hardship suffered. They continue to ask for free electricity at least. The only enjoyment they have is television. I hope the Minister in the budget will remember those people.

There are many dedicated people who are giving time and effort to providing essential services for those in need. I have already mentioned the value of their work. We must encourage more and more involvement. We talk about a comprehensive health policy. I believe we can never achieve this without the voluntary effort. To keep an old person in hospital at present costs about £27 a week. There are people involved in community work keeping old people in their homes for less than half of that.

The pre-school play groups are an essential service. To some extent the Department of Finance are financing this service. I applaud it. It is of vital importance because a number of mothers are returning to employment to increase the income of the home. It is essential to have services available for their children in their absence. Here I want to strike a note of warning. This service can easily be abused. You can have people making available their homes or a room or an attic and charging a £1 an hour or £2 for half a day and yet the child's health can be at risk. I would ask the Parliamentary Secretary to examine this service so that there will be no abuse and that the people who are providing this service, and it is an essential service, will have to comply with certain regulations so as to avoid any danger to the health of a child. I would go so far as to say that licences should only be issued to people who provide the proper facilities.

Are those the boarded-out children?

Did Deputy Coughlan sleep for a while?

The Deputy has only been here a few wet days. This is complicated. There are adopted children and there are boarded-out children.

The Deputy does not know it all.

I know more than the Deputy and that is saying nothing.

Deputy Pearse Wyse. There is only a very limited time for this debate. Will Deputies cease interrupting?

Food hygiene is an aspect of the work of the Minister's Department. Here there is neglect due to the fact that we have not got sufficient inspectors available to the different health authorities. We have seen a lack of hygiene in public-houses—not in all of them—and have seen it in restaurants and in the kitchens of hotels and restaurants. Such places are not in the majority in this country but there are risks.

What happened at Portlaoise?

There is a need to review the position and I am glad the Parliamentary Secretary agrees with me. So far as food hygiene is concerned we need more health inspectors.

The Minister mentioned that a number of social workers were recruited during the year but the number is not sufficient. We were talking about back-up services and voluntary effort. Voluntary effort needs these back-up services if it is to succeed. It can be organised and helped by professional people.

I was reading theReport on the Development of the Social Situation in the Community in 1973, published in Brussels in February, 1974. This is an addendum to the Seventh General Report on the Activities of the European Communities' in accordance with Article 122 of the Treaty of Rome. With regard to social workers, this report states:

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

I was about to quote from the Community report with regard to social workers. It states:

The change in the very role of social work is felt in all countries for the time has passed when mainly a curative function was attributed to it. Social workers cannot confine themselves to helping those who live in intolerable situations without trying to change those situations; their role is increasingly that of "detectors of need" and "agents of change".

As I understand a number of other speakers are anxious to make their contributions I shall conclude with that quotation. I have no doubt the contributions will be constructive, unlike the attitude of Deputy Coughlan since the commencement of this debate.

I am glad of an opportunity to speak in this debate because I tried to raise a matter in regard to the Midland Health Board area which concerns my county. At a meeting of the Midland Health Board a few months ago it was unanimously decided by way of resolution that two mini-scale hospitals be erected in the region. Nobody has been able to clarify for me if the erection of these two hospitals will mean closure of the county hospital in Tullamore. I believe that will happen so far as surgical services are concerned and this is a serious matter for the people in Offaly.

Last June, at a meeting of the Midland Health Board, it was decided unanimously to build a regional hospital. However, something went wrong because in November the proposers changed their minds. They decided to erect two mini-scale hospitals—I would call them Mickey Mouse hospitals—but nobody will tell me any more about them. Deputy O.J. Flanagan talked about it but he kept a foot in each camp, as he is doing on the EEC.

He is a good politician.

Members from Longford, Westmeath and Laois— with the exception of Deputy Flanagan who decided to row in with Offaly—ganged up on us and decided that the mini-scale hospitals were the right choice for the region. Nobody has told us what kind of hospitals they will be but as far as I know they will merely have a few extra beds.

The FitzGerald Report, page 125, deals with the Midland health area. Professor FitzGerald and members of his board went into the hospitals throughout the country, decided that a regional hospital was the best for the Midland Health Board area. I believe this man is very eminent, with a good medical background. When I challenged some of the members of the Midland Health Board about the decision they made and asked them why they made it and why they changed their minds they were not able to tell me. They hedged.

We are not in favour of this arrangement and neither are the people in Offaly in favour of it. They do not want either Mullingar or Portlaoise closed as surgical hospitals. We believe there should be a general hospital in the area and we believe Tullamore is the ideal location for that hospital. At the moment there are patients in the corridors in Tullamore and Mullingar and sometimes there are patients in the corridors in Portlaoise as well. In Tullamore county hospital a new X-ray department is being erected. I understand the equipment is out-of-date. I believe the equipment should be modern equipment.

Sure, it is only a secondhand Government we have.

We also need a new operating theatre and a new children's unit. If an infectious disease broke out I should not like patients brought into the county hospital, especially child patients. I do not know where one could put them. That is the position.

We will not have an opportunity of raising these matters again for some time to come. I believe we should have a new regional hospital for the area with general surgical, general medical, obstetrical and gynaecological departments plus an intensive care unit and an ear, nose and throat unit as well. There must of course also be a casualty department and a nurses' training school. Some may say that this general hospital should go to Mullingar. That would mean that the southern end of Laois would be 50 miles distant from such a hospital. If it were sited in Portlaoise Longford would be about 50 miles distant. General opinion is that a general hospital is the right thing for the Midland Board area and not mini-hospitals. I have no intention of running down either the hospital in Portlaoise or that in Mullingar. I believe they should continue as surgical hospitals and that a general hospital should be sited in Tullamore. I believe Deputy Enright will agree with me in that.

If the Minister goes ahead with mini-hospitals and that results in the running down of Tullamore the people of Offaly will rise up in revolt; we will oppose it tooth and nail. I hope the Parliamentary Secretary will inform his Minister of that.

In reply to a parliamentary question about Tullamore hospital the Minister told me he could not give any undertaking in regard to the county hospital in Offaly. A serious position has now arisen. The staff are growing very uneasy wondering will they get a letter some morning saying their services are no longer required, thanking them for their help in the past and wishing them the best of luck in the future. This is the cloud that is hanging over the county hospital in Tullamore. It is bad for the morale of those caring for the patients and it is bad for the patients. I believe the staff are now starting to look around to see where they will go.

That is not correct.

That is not the truth and it is not fair for Deputy Connolly——

Order, please. Deputy Enright must cease interrupting.

The warning sign has gone up. There is a cloud hanging over the hospital. Deputy Enright may remember that the chief physician on the Offaly health committee, Mr. Hughes, clearly stated there was uneasiness among the staff in the county hospital and Deputy Enright did not contradict him. Why did he not contradict him? Deputy Enright cannot have one foot in Portlaoise and the other in Tullamore at the same time. I went to the meetings when they were called. I did not send a letter of apology, dodging and hedging, as the Deputy did. I stood up to them. I took them all on. They knew I was right and I can go back into Portlaoise but Deputy Enright cannot because he is afraid to face the people.

There was no free vote there either.

Deputy Dowling is quite right.

Is there a mental hospital anywhere near?

The Deputy should be in one. I hope the Parliamentary Secretary will convey my remarks to the Minister. I would be glad if a decision could be made on the future of the hospital as soon as possible from the point of view of the staff, the patients and the people of Offaly. I should like to pay tribute to those looking after the mental hospital in Portlaoise. They are doing a very fine job. At times we hear comments about mental hospitals but the Laois/ Offaly mental hospital is very well kept and the patients are well catered for.

I will withdraw my motion to refer back and I will agree to this Estimate on the basis—I want to spell it out clearly again—that a motion will be put down after the 1st April to the effect that "Dáil Éireann takes note of the activities of the Department of Health for the financial year 1973-74" and that time will be given for the discussion of that motion.

Motion to refer back, by leave, withdrawn.
Vote put and agreed to.
Vote Nos. 20, 21, 22, 36, 26, 27, 28, 31, 32, 33, 37, 40, 41, 42, 44, 45, 46, 1, 2, 6, 8, 10, 15, 16, 19, 49, 50 and 48 agreed in Committee, reported and agreed to.