Health Contributions (Amendment) Bill, 1974: Second Stage (Resumed).

Question again proposed: "That the Bill be now read a Second Time."

Mr. Esmonde

There seems to have been a fair amount of sound and fury in relation to this Bill providing for increased health contributions and one must, I think, look at the matter in the context in which it arises. One can see that the present contribution of £7 per year or 13p per week has been in existence since 1971 and there is no doubt that the cost of the health services has almost doubled since 1971-72. This has been partly due to increased costings and partly to improved services and I think we should take a realistic view of this contribution which is now asked for of 26p per week or £12 per annum. In effect, what these contributors are asked to pay is less than the price of 20 cigarettes per week and bearing in mind the increased and better services, it is a small amount to ask people to pay. I know that times are difficult and costs have risen right across the board but for people to get excited about the fact that they are being asked to pay less than the price of 20 cigarettes per week just does not seem sensible, having regard to the excitement that is being generated from the Opposition benches.

The health contribution to date brought in £5 million per year and this will bring in £3½ million, and if one estimated it, one would probably find that the actual benefit which people in this category receive when related to what they are asked to contribute is something like 10 per cent, if even that. As the Minister rightly pointed out, the contributions to date bear very favourable comparison with those required in other voluntary insurance schemes, be they run by private institutions or by the Voluntary Health Board. I personally have always been an advocate of contributions towards mental services and I think that viewpoint is gaining strength in the country. One hears a lot of criticism about people wastefully and unnecessarily availing of medical services. If there is this situation, it means that unnecessary and increased costs are being visited on the nation and this ultimately has the effect of restricting the availability of health services, institutional or otherwise, which could be made for the rest of the nation and preventing other categories being brought in for what one might call subsidised benefits.

One must look at this Bill in the light of the Estimate for the Department. One sees that the Estimate shows a 40 per cent increase and this means that money has to be found. The average person today would not be prepared to accept the medical services and the medical treatment provided ten years ago. People now demand a better standard of treatment and they demand services on a much wider scale than were heretofore considered sufficient. I was glad to hear the Minister when introducing his Estimate refer to community care.

I can look at medicine from what is a slightly privileged position being the son of a family doctor. I can see the tremendous improvements that have occurred in medical science. Cases that were utterly hopeless and untreatable, except in a palliative sense, are now treatable; conditions that would have incapacitated people years ago can now be corrected and those treated can live normal lives. I was very impressed on visiting a hospital outside the city environment to see people well over 70 years of age undergoing major bone surgery, people who prior to treatment were hardly able to move. They had every guarantee that, if they underwent major surgery, they would be vastly improved physically but, even more important, they had every guarantee they would survive the surgery. This is just one piece of evidence of the improvement in medical care and medical surgery. Many of my constituents have availed of the service in the hospital to which I refer. They pay the contribution of £7 a year under the Health Act. In return they are provided with a truly wonderful service for this very small sum. I am a contributor to the VHI because I do not come within the £7 a year category. I do not begrudge the money I pay to the VHI though the contributions are a great deal higher per capita than would be the case if I were in the category paying £7 a year. This bears out what the Minister said; the requirements of this Bill compare very favourably with the payments under the voluntary health insurance scheme.

It is becoming very apparent that re-thinking will be required in the implementation of the health services at all levels. One has only to walk through the corridors of this House and discover for oneself how many Deputies are carrying antibiotics in their pockets. We are living in an antibiotic age. If a person develops a sniffle he runs to the doctor and asks for an antibiotic. He does not wait for the doctor to prescribe. I am told by doctors that patients actually name the medicine they require. The doctor is in a difficult position because he has got to keep the confidence of his patient. This is vital in all aspects of medicine. There is wide and wholesale abuse of antibiotics and one now actually hears people inveighing against antibiotics and their abuse. Over-usage is amply demonstrated in the huge range of antibiotic drugs available and in the enormous sums of money made by chemical firms churning out antibiotics. I do not know what the figures are but it would be a useful exercise—it is information the Minister might be able to obtain for the House—to make a comparison of the quantity used and the money spent on antibiotics today as against ten years ago. Even making allowance for inflation and increased costs I believe there would be a very large figure as a multiplier to explain the difference in the figures.

The Minister, when introducing his Estimate, referred to his ambitions in respect of general surgical hospitals and general surgical treatment. I assume that includes physician treatment. This is a vital service that must be provided. I know there are difficulties. I know there are competing interests. I know that people want hospitals. I know this is under investigation. It is a thorny problem because one is dealing with humans, with local loyalties and local history. The service is a vital one. It is one that must be maintained at the highest possible level and it is in relation to this service that this payment is required to provide some sort of subvention towards the service.

I have been told over and over again by constituents that they regard the £7 a year as very, very cheap indeed. When one bears in mind the cost of a fully paid patient in a general hospital at today's prices, this payment is minute in relation to the actual cost. One does not need to produce statistics to prove that. Every family is aware of it, particularly those families which have had to bear the cost of surgical medical treatment in a general hospital, not to talk about a specialist hospital. On many occasions, in my capacity as a public representative, I have had to make representations on behalf of constituents because they were not in a position to meet the bill presented and a system of instalment payments had to be arranged.

We should be realistic in our approach to this Bill. We should realise what it means and what it will provide for those who come within the ambit of the scheme.

In relation to general hospital costs and expenses I believe, and many other people believe, that sometimes there is an undue demand on the hospital services, a demand which need not necessarily be made and, if not made, would not harm the patients. There is an undue demand on the X-ray service for comparatively minor injuries which could be diagnosed and dealt with clinically in the doctor's surgery. I also believe that a great deal more minor surgery could be done by ordinary practitioners instead of referring the patients to hospital.

I have in mind in particular the suturing of patients after accidents. It seems to have become a regular procedure that, if a person has a would, he is referred to hospital for suturing. That used not to be the case years ago and many doctors still do their own normal suturing in accident cases. A tremendous number of the medical profession are referring these patients to general hospitals. Very often the suturing which is carried out in these hospitals is done by young doctors who have just qualified. I cannot see why general practitioners with years of experience behind them cannot do this work themselves. If they did, they would be taking a fairly substantial load off the expenses involved in the running of general hospitals and particularly out-patients' departments.

We are all aware of the congestion in the out-patients' departments of general hospitals. Many of the patients in the out-patients' department need not be there and should not have been sent there by doctors. I know the general public have direct access to the out-patients' department after accidents. When they have gone to a suitably qualified doctor, an able doctor, I do not see why that doctor cannot carry out minor surgery himself in the nature of suturing and ordinary repair work of that kind.

I have already said that I regard the too free dispensation of antibiotics as a bad thing. We are going through this period at the moment. It is world wide. It is rather frightening to see the difference in the prices of antibiotics. A first-class book is available to every medical practitioner. It is freely availed of and freely used by practitioners. It is a little book called Mims. I understand that a Deputy of this House is responsible for its production, its design and up-dating. It is a most efficient publication. General practitioners, public health officers and doctors avail of this book. It is produced regularly.

If you look at this book you will find that it puts the various drugs and antibiotics under various headings, says what they are used for, also gives their contra-indications.

It also states—and this is where I take issue with the medical profession in the use of modern drugs—the price of the drugs at retail level to a patient. I have seen a difference of from £1.20 to £5 in the price of antibiotics used for exactly the same condition. Just because one happened to be the most recent one it was being used as the new thing. It was not called penicillin; it was called something else. It was a new name. There is a sort of game of keeping up with the Joneses, keeping up with the new stuff.

I take issue with certain doctors who say they want to do clinical trials on a new drug to satisfy themselves that it is the right one for the purpose. Surely these drugs were tested before they were put on the market. Surely there is information in medical literature on what they can and cannot be used for. Why should a general practitioner indulge in this sort of clinical trial? The main offenders are the younger brigade of general practitioners. I am not saying they are necessarily doing wrong, but they are increasing the cost of the medical services unnecessarily. They are doing work they may not be fully qualified to do. If the drugs have been passed for a certain purpose, they should be used for that. They should not just pick the expensive drug.

Where there is a difference of from £1 to £5 for pills or antibiotics for a certain condition, the doctor should stop and think and have regard to the cost and, if the cheaper medicine can do the job, it should be availed of. There might be a tendency where medical card cases are involved, and where there is free medicine, for doctors to avail all too freely of these expensive drugs which are not necessarily required for the condition being treated. Unfortunately all of us are being made to pay for that.

I know I would be severely criticised in medical circles for suggesting this, but it is time that we started to think about a national formulary. If a booklet of 100 pages or so can be produced by a private concern which is regularly availed of and used by the medical profession, I do not see why something cannot be done at national level and only certain drugs made available for free medicines. This can be done. It would help to control the situation.

It is very hard for the Government in a small country like this to control the price the manufacturer puts on a new drug. It could be controlled by the process of exclusion and inclusion in a national formulary. This message should be brought home to the doctors. I mentioned this at a public meeting recently and a certain medical man took issue with me and said it was not feasble. He did not give any reason. I should like to know why it is not feasible to introduce a national formulary. Under the old dispensary system a code of that nature was used. Doctors have told me that was the position. Even making allowance for difficult and rare conditions that can occur, when a special drug has to be used the doctor can prescribe it and a claim for reimbursement can be made. It must be justified in the circumstances of the case. This loose prescribing in the sense of not having regard to the costings involved has in large measure increased the costs of the health services.

I know the Minister is very keen on the community care programme. I should like to see something being done in conjunction with the community care programme in relation to education on health. Many of us have been reared on the basis that to talk about health is being neurotic, that one is a hypochondriac if one takes an interest in health. The view has been: leave it to the doctor on a sort of witch doctor basis. It is about time that our education should bear in some way on the fundamental of physiology, on normal good health and on how people can manage themselves.

If people were educated on health to a better extent than they are or could be by reading articles in newspapers or magazines many of them would not have to have recourse to doctors. If anyone asks the average family practitioner what percentage of his patients have a sort of nerve condition and are given tranquilisers or reassurance and yet have not got a physiological problem, one finds that the percentage is very high. That is largely born out of ignorance and fear. I am speaking from a slightly privileged position in this regard being the son of a doctor. I have seen cases, heard of cases and spoken to patients on this matter of health. I have come to the conclusion that if one can reassure such patients they are new people.

When one considers the contribution called for by this Bill one must bear in mind that in 1972-73 £36 million was provided out of the rates for our health services. In 1974 that figure was reduced to £13½ million. This has meant a tremendous load off the rates and that will be to the benefit of many people who are contributors under this scheme. However there is more to it than that, because certain counties are better off than others. Some counties have been able to find money easier for health services in their own administrative area. Putting the money on the Exchequer has meant an evening up of the general health service across the country. It has meant that there is no discrimination between the wealthy area and the poor area.

Deputy O'Malley referred to the fact that contributors to the Voluntary Health Insurance Scheme, in order to qualify for benefit, must spend 24 hours in hospital. I understand that is still the position. It was the position some years ago when I availed of the service. At that time I had to go into hospital for a test which could have been done in a matter of hours but, in order to avail of the scheme, I had to be booked into the hospital for 24 hours. I regarded this as unnecessary. The Voluntary Health Insurance Board would be doing a good service to medicine in general if they had another look at this aspect of their scheme because this means that people are unnecessarily occupying beds in general and other hospitals.

I know that an ENT specialist in order to save money for the parents of a young person who had had his tonsils removed arranged to have a taxi waiting outside the out-patient department of the hospital so that the child could be sent home immediately after the operation. When the parents sought recoupment from the Voluntary Health Insurance Board they were told they could not qualify because the child had not spent 24 hours in hospital.

I may have been critical in my contribution in relation to the use of antibiotics but I can plead a certain amount of bias because for things like the common cold and so on I do not avail of antibiotics, I use herbs. Many people consider that peculiar, but herbs were good enough for my grandparents and, because they give me the desired results and alleviate me of the aches or pains, they are good enough for me. The old and tried remedies can bring the same, if not better, results and in many cases a much quicker cure than the standard antibiotic type of treatment.

At the outset I said that I was in favour of contribution for a service but I believe also in involvement by the public in our health service. This has been very apparent in relation to mentally and physically handicapped people, particularly young people. There has been a wonderful surge of interest in this regard. The movement started on a purely voluntary basis and, although it has been only a few years in operation, a tremendous amount of voluntary work has been done in those fields. I do not think that the present care for handicapped people would be at the stage it is today were it not for the impetus given by voluntary workers. In this regard the State is a latecomer to treatment of these people but, even though the State has since become involved, those who worked in a voluntary capacity in this field have not backed out or sought to do less work. The contrary is the position. There has been an increase and ever growing interest in this field. There is a lesson to be learned from that and it is one that might be applied when we come to consider the community care programme the Minister has in mind.

If there was voluntary participation by people that scheme could be far more successful. When people are voluntarily involved in a scheme of this kind such a scheme tends to be more successful. I am certain that there are many married qualified nurses who would be prepared to assist in such a scheme on a purely voluntary part-time basis.

If these people were allowed participate in such a scheme, it would get off the ground much quicker and be far more successful. I know people will argue that one might be doing somebody out of a job. I do not think there is any fear whatever of that allegation being made in relation to community care services because, certainly at the beginning of this proposed scheme, there will be less than is required; the demands will be far more than can be met. There is plenty of room for voluntary involvement at that level. That, coupled with health education, could improve the general health of the nation and redound to everybody's benefit.

I see also that the Minister is taking a very keen interest in child health services. This is something that should be given the utmost support because a lot of illnesses have their seeds sown in the young age groups and, if not attended to at that age, can have very deleterious and serious effects on people in later life. We are aware of that in regard to heart cases. Modern heart surgery has brought a lot of light to bear in this regard. We are also aware that kidney complaints can ultimately result in a severe mental handicap. These are all recent developments in medicine. Therefore, the original child health service provided in national schools was insufficient in the light of present-day knowledge.

I am glad to note that the Minister is taking a particular interest in this field because children cannot protect or provide for themselves. It has got to be done by an outside agency. The all-seeing eye of a good health service is required in this regard. One could talk for a long time on the subject of health, which is a rather emotive one but I think I have said enough. I would ask the Opposition spokesman— I know Deputy G. Collins is full of fire and brimstone and will rise to his feet when I have concluded—to remember that there has been no increase in the charge to contributors since 1971 while wages, costs, everything has risen, the new charge called for is less than the price of 20 cigarettes.

Mr. G. Collins

First, I should say that the Minister for Health is welcome into the House with this legislation, it being the first he has introduced since he became Minister for Health. At the outset, one is temped to ask the Minister why it took him 20 months to bring legislation before this House. Members of this House, the medical profession and the public at large know full well that there is much the Minister for Health could be doing. A lot of what can be done can be done only when it has been passed in and approved by this House.

There are those who say that the Minister for Health is slightly nervous in coming into this House with legislation, possibly afraid of criticism not alone from this side of the House but from Members on his own side and, in particular, from members of his own party. I shall deal with Deputy Esmonde's contribution in a very short time but may I say that, in the period of 20 months during which Deputy Corish has been Minister for Health, we have had the minimum discussion on the affairs of his Department, despite undertakings given by him that full discussion would take place. Naturally, one asks oneself the question: "Are these public undertakings to be uttered when forced to be given and to be forgotten when the time comes for discussion?" I know that the Minister for Health, during his time in public life, has taken his share of criticism, publicly of course, from the Opposition whether or not this party were in Government. But I do not think our criticism would be sufficient to prevent the Minister coming into this House and affording the people here the right which is theirs, the right to discuss health matters. Perhaps the Minister is super-sensitive to the criticism he knows he is getting, publicly and privately, and will get publicly from members of his own party.

This Bill has been described as fraudulent and hypocritical by members of the Labour Party. I would refer the House to the contribution made by Deputy O'Connell when this Bill was introduced by the Minister yesterday. One would never think, having listened to and read what Deputy O'Connell said, and having listened to Deputy Esmonde from Wexford, that they were talking about the same thing. Indeed, Deputy Esmonde, in concluding his contribution, inferred that I was not too comfortable looking in my seat here, that I was waiting for the opportunity to get in and express some of the opinions I hold. Of course, he was right. In the course of his contribution, which lasted practically 45 minutes, his opening and closing sentences only dealt with the matter before this House. Let me add further that his opening and closing sentences were exactly similar, that is, that the percentage increase required can be dismissed instantly because of its smallness. He likened the increase to the price of a packet of cigarettes and left it at that. As for the remainder of his contribution, it would appear that he had an obsession with antibiotics. I suppose he can be allowed an opportunity of registering his personal dislike for their use any time he likes. But it is difficult to understand how he felt that this was the right time and place to do so. Everybody who has come to the use of reason knows that antibiotics are given always on prescription. Certainly I have enough faith—if Deputy Esmonde has not—in the medical profession to issue antibiotics only when necessary, on prescription, to those in need of them. Might I point out another criticism he had to voice which was one levelled at the demand on the hospital services? It would appear from the approach of Deputy Esmonde that any person, for any reason, could walk off the street into a hospital and demand service, demand a bed, room and doctors and nurses to look after him. Of course, that is not so and Deputy Esmonde— who is in the privileged position of being the son of a country general practitioner—should know at least that doctors have a very great say in sending patients to hospitals for care and attention. Might I say further, for fear his fellow-countyman, the Minister for Health, might be influenced by him, that the advice he gave that people injured in accidents should not be brought to hospital for treatment, that there should be treatment provided in places other than hospitals, is something I cannot accept in the bland fashion we heard it expressed.

Deputy Esmonde is very wrong in his thinking on this. He is very wrong when he says the patient would only be attended in hospital by young doctors. I want to say to him, if nobody else from his party or the party tied up with them say it to him, that the people owe a big debt to the young doctors who have been running our hospitals for us. Deputy Esmonde's contribution is no more than a smokescreen to try to cover the fact that this Bill is nothing more than a tax Bill.

There are people who believe that this Bill, seeing it is doing what it is planned to do by those promoting it, could have waited until the budget day although the last week would lead one to believe that budget day on 15th January next is not really that day as we knew it but that we are having a budget every day. This is the third blow in less than a week to a very weak sector of the community, who are not as well organised as one would want them to be if they were to speak up on their own behalf and protect their interests.

The penal taxation measure by the Minister for Health, together with other actions of the Government in recent days, the unbelievably high increase in the price of petrol and the very steep increase in the price of a pound of butter, which we learned of yesterday, all add up to a large increase in taxation. The people most affected by these new demands on them are those whom, I am sorry to say, the Minister for Health and members of his party are at great pains to tell us they represent. My interpretation of representation is different from that.

Almost every day in recent times we find increases in the price of goods of all types. The natural consequences of these varied prices is that it is becoming increasingly more difficult for the poorer sections of the people to eke out a living. The Labour/Fine Gael Government are guilty of grave indifference to the problems of the poorer section of the community. Those people who have supported the Labour Party and what they stood for have now the feeling of being let down with a bang. They have the feeling of being neglected and thrown to the wolves but they are not as gullible as some of the people on the opposite benches think they are. They will not exonerate the Government and blame the Arabs, as they are told to do, by the well-geared public relations section of the Labour/Fine Gael Government.

It is easy for those who want to play with figures to say that the increase is only a matter of pence. That is not so because the people involved had no say in the matter. They were not consulted and their co-operation was not asked for. When I say that I am reminded of an answer given by the Minister for Finance at the end of Question Time today, when he spoke rather loudly but with his tongue in his cheek, in regard to a statement made by the Taoiseach in this House during the first days of the Labour/Fine Gael Coalition when he said that consultation with all sectors was to be the key word of the new administration.

We will find, when the Minister for Health has his Bill tucked under his arm when he leaves this House and goes to the Seanad, that the working man will have had no say whatsoever, will not have been asked whether he minds about this increase in his contribution for health. It will be taken from him, whether he likes it or not, because it will be taken out of his pay packet.

The people I referred to in the category who will now pay £12 a year contribution under this Bill—it was £7 before this—are the small farmers who are in a slightly different position from those who will have money stopped at source. They will have the opportunity of being notified that their subscription is due and will be able to think about the sting when they have to pay the high percentage increase demanded of them. It was said in recent times that difficulties were being experienced in the collection of moneys in lump sums. If difficulties existed in getting sums of £7 from those who were participating in the scheme there will be real difficulty now in collecting this money particularly from the small farmers who can see practically everything going against them. They can see they are always being used by the Labour/ Fine Gael Government when it suits them and not when it suits the small farmers. Their incomes have been reduced to a very low amount. Many of them are experiencing conditions which they thought they left behind them in the thirties when they suffered a loss as a result of the economic war. Now, because of the failure of the Government in many fields, because of their action in some instances and lack of action in other instances these people are in extremely bad financial difficulties. Despite this they are being asked for increased contributions by the Minister for Health.

I see real difficulties. If the Minister agrees that the poorer sections of our community should be hit for more taxes, then he is not the man I thought he was, because you never hit a man when he is down. The people who are being hit or who will be hit in their pockets when this Bill is law are the people who at present are down pretty low. The small farmers who are eligible to participate in this scheme are low down and the working man must be down because of the fantastic and innumerable increases that have taken place over the last so many months.

People are punch-drunk nowadays from increases. They do not know where it is going to stop. If the Tánaiste and Minister for Health wants proof of what I am saying, I can give it to him openly and clearly, and I shall do it now, in that those who supported him and his party from that sector of the community have clearly indicated their dissatisfaction and displeasure with the people whom the Minister for Health leads in this House. Proof of this was seen in the most recent test we had with the electorate in North-East Cork.

Mr. Taylor

We held our own.

Mr. G. Collins

The election results take some time to analyse and study. Perhaps the Deputy who said "We held our own" has not completed his study. However, the Deputy who said he held his own, a Deputy who supports the Coalition Government, is not in this instance speaking for the Labour Party, because they did not hold their own; they got a hammering in the most recent test at the polls. There are people who are being hit hard, if the utterances of the Labour representative, Deputy Dr. John O'Connell, are to be believed, and let the Press take note that Deputy O'Connell was for a long time the spokesman appointed by the Tánaiste to deal with health matters when they were on this side of the House. He has criticised things that have been done, and, let that be recognised as a very clear and very powerful warning that things are not well if they continue to operate as they are doing.

Deputy Esmonde glibly but unsuccessfully, in the same manner as he dismissed the percentage increase in charges, tried to dismiss the contribution to this debate by our spokesman on health matters, Deputy Desmond O'Malley. I have read more than once the unrevised reports of what Deputy O'Malley said in this debate for my party. While he was highly critical, as rightly he should be, his remarks were very fair, constructive, and to the point. It was with regret I listened to the third Limerick man who participated in this debate—a member of the Minister's own party, a man who is publicly known for his political indiscretion, his coarseness and earthiness—and who, following the fine contribution of Deputy O'Malley, descended, even for him, to a new low level in his criticisms and in his personal attack on Deputy O'Malley.

Mr. McDonald

The Deputy is well qualified to judge him.

Mr. G. Collins

I am not at all taken aback by the interjection of the junior Fine Gael Deputy from the Laois-Offaly constituency. I am just wondering whether I shall even bother to answer it. I do not think I shall, because the senior Deputy from the constituency representing the same party as the gentleman here is more than capable of dealing with him in his own unscrupulous manner.

Acting Chairman (Mr. M.E. Dockrell)

Personal remarks on both sides of the House are to be deprecated.

Mr. G. Collins

In passing through this House yesterday evening I saw Deputy Coughlan trying to work himself into a state of fury so that at least those who were looking at him might feel that he was running with the bit between his teeth. All I can say is, having listened to him and having read what he said, that his laboured efforts showed his small-mindedness and his pettiness and that there is more to it than meets the eye. Perhaps it is that he is very sensitive in his present political limbo and that he is also aware of the fact that Deputy O'Malley commands the respect and support that he does in Limerick city and the part of the county that joins with it to make up that constituency. Those who are in glasshouses should not throw stones. I am sorry, Mr. Chairman, that you were not here yesterday to hear his contribution. It was the first time in my political life that I heard a Member publicly damn and curse another Member of a party in this House. The actual words are on the record for anybody to see, public damnation and cursing in a personal way of the man who went before him.

Mr. Taylor

Do not forget the——

Mr. G. Collins

This is a deplorable effort by Deputy Coughlan and on behalf of the party he represents. It was more deplorable still because it was said in the presence of the Leader of his party, the Minister for Health and second in command of our Government.

Acting Chairman

Deputy G. Collins has made it abundantly clear that he did not agree with any remarks made against Deputy O'Malley——

Mr. Power

This is the first opportunity I have had to compliment the Minister on his good work. I thank him for his courtesy and interest in any problem with which I approached him during the year.

I am not happy with the provisions of the Bill. In essence, it is a scheme to raise money in the best possible way—not the best from the health point of view but in a manner which is less politically painful and more politically palatable to the electorate. That is the guideline the Minister used when setting about this Bill.

The increase to 26p per week, or £12 per year will bring in £3½ million. Who will pay it? It is the working man who can least afford it who will be called upon to pay. Admittedly, the £7 scheme was a good form of insurance for the ordinary man.

The Irish Hospitals Sweepstakes charge £1 for their sweep tickets and have done for a long time. To increase the charges might not be the best thing to do. To increase the contributions to £12 might not have been the best thing to do either. While people might have found it hard to contribute £7, to find £12 is another kettle of fish. Smallholders and small farmers whose incomes have dropped will not find it easy to get £12.

The thinking behind the Bill is completely at variance with Coalition promises. They promised that health charges would be removed from the rates. That would have been good if it could have been implemented. I agree that efforts have been made to implement it and it is being phased over a period. In my view this measure will put a greater individual health tax on the worker or small farmer. I cannot reconcile that with the thinking and promises of the National Coalition parties before they came into office. To my mind those promises were never backed up with a determined, constructive and continuous policy geared towards funding its removal. They should have known what was going to happen. If the implications of their promises had been analysed they would have seen that a great deal of money had to be found. This stop-gap measure proves that they did not plan for this. It also convinces me that there is no continuity of policy in the Department.

Before the Minister took up his portfolio, the Department was under the aegis of the late Mr. Childers. At that time the Department of Health was in a healthy state. Great strides were made then. Better conditions were obtained for all members of the medical profession. Big problems were seriously tackled, such as the setting up of the health boards. That was a formidable task. There appears to have been dialogue at all times. There seemed to be an air of "I know where I'm going and I know who's going with me" so far as the Department of Health were concerned during the Fianna Fáil administration. The theme song of the present administration is something of a more modern nature, more in keeping with the socialistic ideology of a Government health scheme for everyone whether they want it or not. "Any dream will do" would appear to be an appropriate theme song for the Minister and the Coalition. The dream they had when they were in Opposition has turned into a nightmare now that they find themselves unexpectedly in Government.

Mr. Taylor

"Steady boys and step together".

Mr. R.P. Burke

Tell Deputy O'Connell that.

Mr. Taylor

"Steady boys and step together" is our theme song.

Mr. Power

The Deputy will find great difficulty in stepping with Deputy O'Connell. He might walk a furrow for a little while but I am afraid the Deputy will find great difficulty in keeping his traces pulled.

Mr. Taylor

Let us watch how he votes.

Acting Chairman

No interruptions please.

Mr. Power

This doctrine of a central taxation funding health is to be bolstered up by greater individual taxation. This is a policy whereby the poor person is paying for something he has already free. Holders of GMS cards will be contributing 26p each week for something they already have for nothing. It might be well if the Minister would look at the policies we are asking him to examine and see if there is not some merit in the suggestion that those who find themselves immediately above the income limit for a GMS card are the people who are hardest hit. Is there not some merit in extending the net to include them?

I have been approached recently by a number of people who are greatly perturbed by the notices they have received informing them that they are no longer eligible for free general medical services. I hope that this is not the situation generally throughout the country. It must be a cause of great anxiety for persons whose incomes are only slightly above the limit to be told that the services will no longer be available to them. For a person with a take-home pay of £30 per week, the imposition of having to pay a doctor's fee might be a great hardship.

While the 26p per week contribution towards health services may not appear to be significant, when added to all the other items in respect of which deductions are made, it could bring a person to the stage where he would ask himself if he might not be better off on social welfare benefits. Anything that would bring about a situation in which it would be more lucrative to avail of unemployment benefit than to work, would be deplorable and the Minister should ensure that no such circumstances will arise.

Legislation such as this proves that there is a wavering policy so far as health is concerned. If our doctors were to carry out a diagnosis of the health portfolio at present I think they would agree that there has been a rapid deterioration in this sphere.

I agree with the principle of some contribution being paid towards the health services. From my experience in another area I can say that when free books were given to school-children or, even when hurleys were given free to school teams, there was not as much appreciation of these services as there was in the case of those people who had to pay for them. The same can be said of medical treatment. Doctors have told me that when treatment is free it is apt to be abused—for instance by patients taking up too much of the doctor's time unnecessarily and very often not bothering to take the medicines prescribed for them. When there is an element of contribution there is less likelihood of wastage.

Our policy should be to care for those people who are most in need. Fianna Fáil have always been consistent in their approach to these matters. It would be very foolish of the Minister to sacrifice such aspirations for any doctrinaire considerations such as free health for all. This may have sounded fine in opposition, but I am sure the Minister will agree now that it is not something that can be attained easily. Indeed we might ask ourselves if such a change is really necessary.

It is essential that we continue to develop our hospital resources. There is room for much improvement and extension of services in hospitals such as Naas, for instance. The Minister is to be complimented on continuing the groundwork laid by the previous administration in this regard. However, while there have been many improvements at Naas Hospital, there is need for a geriatric unit there. The Minister tells us that money is scarce. I suppose this means the non-availability of the capital expenditure required for the further development of hospitals but let us not lose sight of the fact that people must be our prime consideration.

I would be concerned lest civil servants in any Department would draw a circle of, say, between 30 and 50 miles from Dublin and say that the necessary services are available within that area. That has not happened so far but we should ensure that there will be no move in that direction. I am happy with the functioning of the health boards but we must guard against decisions being taken that would mean the centralising of services, thereby, denying people in the peripheral areas the services that should be available to them.

The care of the aged is very important and every effort should be made to make it possible for people to be kept at home in so far as is possible rather than to be sent to hospitals or institutions. I know of many patients who are occupying beds for long terms in hospital because there is nowhere else for them to go. To give an instance of this, I was speaking to a man on Sunday last who told me that because he has no house he has been forced to stay in an institution in our county for some time past. He appeared to be in perfect health and told me that he was 54 years of age. He was hoping to get a pre-fab erected for him. Some greater liaison should be seen to be working between the Departments of Health and Social Welfare to provide people like him with alternative accommodation rather than to have beds in hospitals, possibly needed for surgically ill people, taken up in that way.

I realise that home care will cost a lot of money but I am positive that money will be spent in keeping people out of hospital. It will require a complete change in the health service structure and a great deal of concentration not only on home care but on health centres and on the rechannelling of qualified personnel. But I am positive it will pay off financially, socially and medically. It will mean big capital outlay initially but I think this is something that will appeal to the Minister.

In this matter of co-operation between the Departments of Social Welfare and Health, a lot needs to be done. The Minister finds himself in the unfortunate position of having responsibility for both. I suggest that health on its own is a very big job and perhaps the two portfolios should be divided to enable the Minister to give his undivided attention to health.

I take the Minister to be an honest man who feels he is right, that he is giving a better service to more people. We on this side feel that he could give an even better service to those who need it most and that those who are able to pay should be asked to do so. Because money is not unlimited, we cannot do all the Minister wants to do. The position Fianna Fáil have outlined consistently is that we should do the best we can with the money available. It is with a view to that that we appeal to the Minister not to increase health charges. He should think clearly that his main job is to look after health, that his main business is the health of the community. He should be guided by the proverb that health is better than wealth.

Mr. Bermingham

One thing about the debate so far which has amazed me is the terrible sense of acrimony in the whole thing—people arguing with one another—while the point at issue was not debated at all. What the Bill is about is an increase in health contributions from 15p to 26p per week or from £7 to £12 per annum. The contribution system has been there since 1971. I know I am correct in that because before I entered the House I was contributing the £7. I do not think the increase being sought now, considering the cost of the services now and the way they have risen, is extravagant.

I am not so sure that the contribution system is worth while because the contributions seem so small in proportion to the overall cost of the health services. Therefore, I do not think it is worth all the talk we have been having yesterday and today and all the bitterness it seems to have provoked. I realise this is one more addition to the ever rising cost of living but I do not think it is a great hardship on most of the people who have been contributing £7 to have to contribute £12 a year. This contribution system was introduced in 1971 and that being the case I find it hard to see how you can argue that the increase to £12 is excessive, that is, if you accept the principle of a contribution at all, and I am not so sure about it.

Speaking about self-employed people and small farmers, the small farmers have the advantage of paying the contributions yearly. On the other hand, there is a type of small businessman or tradesman who operates as a self-employed person. I know of one such person who has a family of seven and who would not normally be liable to contribute. He was in a small tin-pot way of business, he did not keep records and did not clear his position with the Revenue Commissioners. If he had done so he would neither have to pay tax nor a health contribution. He never bothered about his health contribution because, unlike a small farmer or any other type of self-employed person, he is obliged to make his contributions through the Revenue Commissioners.

There are many people like him. For many years people in small businesses such as blacksmiths, garagemen in a small way and so on, have not declared themselves to the Revenue Commissioners. They have been terrified at the suggestion that they would have to pay these contributions. They are fearful of going near those people to clear their cases. In most of those cases they would have had no difficulty but there is this inbred fear of going to the Revenue Commissioners.

My colleague from Kildare has said that medical card holders might be asked to pay this 26p. That is not correct. A medical card holder is entitled to produce his card to his employer who will not then stop the contribution. If such a person does not wish to disclose his position to the employer, he can get a refund from the Revenue Commissioners.

Dr. O'Connell

I do not think that is correct. He has to get his contributions back from his employers. The Minister mentioned this.

Mr. Bermingham

He has other methods of getting them back.

Mr. Hussey

Let there be no acrimony.

Mr. R.P. Burke

Let there be no unseemly rows between members of the Labour Party.

Mr. Bermingham

I do not go in for rows. I say what I honestly think and I do not go in for cross-talk like that which has been going on here during the last day or two. It has not been too edifying. A person with a medical card is not asked to pay this contribution.

The contributions are to be increased and that is what the Bill is all about. I am now asking the Minister to examine whether it is worth all the bother of collection and all the trouble being put on people to stamp cards. However, the base was laid in 1971 and the Minister was entitled to look for an increase, not that I think the contribution system is the correct way.

I am not altogether satisfied with the operation of the Health Act and with the health boards. I am a firm believer, as far as County Kildare is concerned, at least, that the system under which the county councils operated gave a far better service—that we lost something since we came under the colossus of the Eastern Health Board. In those days, the health services were administered by people who were in touch with the local communities and who understood their circumstances, people who knew those entitled to free hospitalisation. Particularly in the southern end of County Kildare, we now have to deal with a lot of faceless people in the health board.

We heard a lot about choice of doctor soon after the Health Act was passed. To my mind it leaves a lot to be desired. I am not saying the old system was better, and when the choice of doctor was introduced, in my innocence I thought it would be good for the people. However, people who are just outside the medical card money, as I would call it, a man and his wife with £20.6 per week, for instance, are not eligible. In this respect one thing that worries me is that there is no obligation on a doctor to attend such people in any circumstances. It frightens me. A person might be able to pay for a doctor. Such people, in my hearing, have been advised by an official of the Eastern Health Board, to register with a doctor, but people with a weekly income of £21 or £22, just outside medical card eligibility, do not go to look for a doctor until they need him. Such a person might live 12 or 13 miles from a doctor and might have to go to such a doctor in the middle of the night but there is no obligation on that doctor to attend him. If a new Health Act is necessary to remedy such situations, then we must have it.

If a person is qualified for a medical card and if he wants choice of doctor he should have it. The doctors were the people who originally imposed the condition that a doctor would have to be practising for two years in a certain place. I say that any qualified doctor who sets up a practice should be able to take a medical card patient if one attends him. I am a strong believer in that and I do not mind who agrees or disagrees with me. That is what free choice of doctor means.

On the question of hospitalisation, a person might prefer, if he is a short-term patient, to stay in a nursing home, a cottage hospital or some such institution. Such a hospital would not be as costly to run as one which would have surgical and other facilities, and I have a feeling that such a patient with such a preference might not get as good value for his contributions as a person who would go to the other type of hospital.

I should like to refer to the Naas Hospital where, unless the situation has been corrected recently, there is not a registrar. This puts the physician in that hospital, Dr. Waldron, in the position that it is only those of the young doctors who are left that he can choose from to staff the hospital. That is because he has not a registrar. This is something that should not happen. Only the best young doctors should be appointed to those hospitals. I am not suggesting that the men who are there in the Naas Hospital are not the best, but they are only what is left after the hospitals who have registrars have been supplied.

I do not think the contributions now being asked for will make any significant contribution towards paying for the health services. I would be prepared to go along with a hugely increased contribution if that would give free medical services and free hospitalisation to the people entitled to them. The principle has been established of contributions towards the health service. The Minister is entitled under circumstances of expanded service and increased cost to seek an increase in the contributions. It would be a wonderful step forward if there were a contribution that would pay even half the cost of the complete medical card. That may not be feasible. I should like to hear some figures as to the amount of contribution that would be necessary both from the Exchequer and from the contributors to bring about that situation.

A free-for-all hospital service is a good thing. I do not think it is vitally necessary but it is good and is something towards which we should strive. I think the Minister has this in mind. I do not think that we have the necessary services available at present that would make this possible. It might impose too great a burden on, say, persons in the hospital services.

It has been suggested by a speaker from this side of the House that there should be some control as to the kinds of drugs doctors would prescribe for patients who come under the Health Act. I dissociate myself from that suggestion. I do not say that the Deputy who made the suggestion had this in mind but the suggestion could be interpreted as meaning that only the cheaper drugs would be dispensed for Health Act patients. This would be a terrible reflection on the service.

Once there was a contribution in the original scheme the Minister is entitled at this time to increase it. I do not think he is increasing it greatly but perhaps the increase is substantial enough. I am doubtful if what the Minister will get out of it will be worth while. The money must be provided either by general taxation or by a scheme such as is now proposed. It has been suggested that the money is now being taken from the poorer section. If the money were raised by general taxation it could be argued that it was being taken from a still poorer section, the unfortunate old age pensioner who might purchase tobacco or a small drink. Therefore I am not too sure that to raise the money in taxation would be better than the system adopted by the Minister. I am prepared to accept what the Minister is doing. I am not too sure that all the talk and all the bitterness that we have had about it over the past few days is justified.

In conclusion, let me say the Minister should review the Health Act which requires to be amended and updated.

Mr. R.P. Burke

I have no doubt that in the middle of next week when this Dáil session concludes and the Government are asked for an account of their stewardship and are asked by the Press and by the public the reason why they did not introduce major legislation in this session the Parliamentary Secretary to the Taoiseach will list a number of Bills that were brought before the House and will say there was a Health Bill introduced in the session from October to December. The only resemblance between this Bill and a proper Health Bill is in the title— Health Contributions (Amendment) Bill, 1974. The only connection it has with health is in the Title.

This is another form of taxation being imposed on the people by a bankrupt Government, bankrupt in ideas, bankrupt financially and trying to bankrupt the people.

I might not agree with the Minister politically but he is an honourable man. At least he had the guts and the respect for Parliament to introduce a Bill to take this extra money from the people, unlike his colleagues. We had the spectacle last week of a device being used by the Minister for Finance to take nearly £30 million from the people by way of an increased charge on petrol. We had the increased cost of butter. Even today there was the ludicrous spectacle of the Minister having one of his backbenchers put down a question about dog licences so that he could announce an increase in the cost of dog licences. How low are the Government prepared to go in trying to take every last penny from the unfortunate taxpayers? For once, Fianna Fáil were not blamed for increasing something such as the dog licence.

Mr. Dowling

We were held responsible.

Mr. R.P. Burke

It happens every time. There is a rumour rife—I am sure it will be denied—amongst many Government backbenchers that even the oil sheiks are carrying Fianna Fáil names. We are blamed for everything.

Mr. Kelly

There are certainly queer hawks who are card carriers, if not oil sheiks.

Acting Chairman (Mr. Tunney)

Perhaps the Deputy would get back to health contributions.

Mr. R.P. Burke

I bow to your ruling. I am heading in that general direction. The Minister for Health has introduced this Bill to take extra taxation. That is what this £3¼-4 million is. This is being asked of the people at a time when there are approximately 100,000 unemployed and at a time when people are not in a position to pay extra taxation. The small farmer is one person who will be hit at a time when he is very badly off.

I would ask the Minister to consider not just the points made by Members on this side of the House but by Deputies on his own side. Deputy Bermingham, who is a decent man, queried the expense involved in the collection of these contributions and he wondered if it was really necessary. He also queried whether this measure would make any contribution to the health costs in general. This was from a backbencher of the Government party, a member of a party of which the Minister for Health is leader.

Deputy O'Connell is conversant with health matters and he was spokesman for health on behalf of the Labour Party. The Minister for Health said a lot about review bodies and we had the startling announcement from him after nearly two years in office that another review body was to be set up. I agree fully with Deputy O'Connell who stated that the review body should have been set up when the Government came into office, not two years later. Of course we are familiar with the practice of the present regime. Whenever there is a problem that needs a decision they set up a review body. Whenever there is a thorny problem before the Cabinet that would necessitate anyone making a decision they set up a commission and put off the matter for another two years, knowing in their hearts they will not be around to make the decision when the time comes because they will be on this side of the House——

Mr. Kelly

It is very unlucky to prophesy.

Mr. R.P. Burke

The only thing that will save the present regime is luck.

Acting Chairman

The Chair would ask Deputy Burke and the Parliamentary Secretary to leave prophecies to Old Moore and the Deputy to speak on health contributions.

Mr. R.P. Burke

In this context health contributions are a form of taxation at a time when the country is in a worse state than any period since the mid-fifties when the last Coalition were in office. We might ask what are we getting for these contributions. The explanatory memorandum states that it entitles people to hospital in-patient and out-patient services. Any Deputy in the Dublin region will know what were the Minister's promises with regard to hospitals. We were told at four different Press conferences that the Minister had cured the hospital problem in Dublin. Probably there will be further Press conferences after Christmas but so far we have not seen any hospital. There has been much talk about a hospital in Beaumont which is adjacent to my constituency and which would probably be used by people in my constituency and in other areas also. I had expected to be invited to the opening ceremony but I am afraid it will be the year 2,000 before construction will be commenced. Notwithstanding that, I am sure we will hear about this hospital from the Minister at least every six weeks at various Press conferences.

What are the emergency services like in the Dublin region? The services, particularly as they affect the area where I live in north County Dublin, leave much to be desired. There is no emergency ambulance based in that area. In St. Ita's Hospital, Portrane, it would be possible to establish an emergency unit for accidents. It is on the stretch of road from Dublin to Drogheda that has a high accident rate and it would be appropriate to have a central location for such an emergency unit, or at least have an ambulance there that could be used for all emergencies. I should like to see some of the money being used for such a unit.

I should like to pay tribute to the staff of St. Ita's Hospital for the tremendous work they are doing in trying conditions. They are very concerned about and work hard for the people under their care and, for that reason, I should like to pay a tribute to them in this House. They are not being paid adequately for the work they are doing. I hope the Minister will review the whole wages and salary structure for hospital staff, particularly the nurses, rather than make appeals for moderation in income demands as he did in his opening speech. He is appealing for moderation of income when all forms of taxation are increasing. We have had taxation of £45 million recently, including the £15 million in respect of the postal charges imposed by the Minister for Posts and Telegraphs, all without a vote in the House. At least we have the opportunity of voting in this case and I have no doubt that the Members on the other side who spoke against it will vote with us and bring about the fall of the present regime.

Mr. Kelly

I hope the Deputy will not put as much money on that as on the North Cork by-election.

Mr. R.P. Burke

Mr. Kelly

I suppose the Deputy is suffering from lack of money also.

Mr. R.P. Burke

I am actually at the moment, very badly, especially in my profession when there is a recession in the building trade which has not yet been recognised by the Minister for Local Government despite the jibes of the Parliamentary Secretary.

There is a reason for the decrease in the number of medical cards which the Minister has not admitted publicly but of which the medical profession are only too well aware. The Minister in his negotiations with the medical union after Christmas will want to make the point that the number of medical cards has decreased and that, therefore, the medical union's case for extra money is not valid because they are not dealing with as many patients. The people are entitled to the medical services that were introduced by successive Fianna Fáil Governments, in particular by the late President Childers, when he was Minister for Health. He was responsible for some far-reaching extensions of the medical services. He was responsible for the major legislation which set up the various health boards. His memory is entitled to greater respect than to be destroyed by the Health Contributions (Amendment) Bill, 1974 which should be called the Fourth Taxation Bill of mid-December, 1974.

Mr. McDonald

I support this Bill. I have been sitting in the House for a couple of hours and, as a farmer coming from a farming constituency it sounds peculiar to me to hear the Opposition urban Deputies so concerned, though I welcome their concern, for the small farmers and the poor farmers. I am well aware of the difficulties many of them are facing but I want to put it on record that the poorest of those small farmers would prefer to pay the new 23p per week charge for the services they are offered under this Bill than to lie in bed, as they did before 1971, worrying how they would pay their hospital bills. It is a very good insurance for those people, whether they are lower paid people or people with small holdings, whether they are paying a weekly contribution or an annual contribution of £12 and I am not minimising that. The sum of £12 is small but it is quite a hefty sum if you have not got it and that will be a problem for some people. Nevertheless, it represents a contribution this year of £5 million for services which are estimated to cost £120 million in this year and it is unfair of the Opposition to avail of this opportunity to castigate the very fine health and hospital service we have. The Irish health services and the people running them can stand up to comparison with those of any country not only in Europe but in the world and I fail to see why at every opportunity speakers, not necessarily from the Opposition, display the Irish tendency always to be critical and to knock. I do not know what our motivation is— I cannot say that I am any different myself—but it is certainly not a European practice because one never hears Europeans knock their services and as a matter of fact, they dress them up in such grandiose language that it is difficult to recognise them, so well presented and spiced up are they.

Mr. Dowling

We are more honest.

Mr. McDonald

I should like to take the opportunity to compliment the Minister, his Department and the fine body of dedicated professional and lay personnel who operate our services for the very fine service they give to the people. It has already been pointed out that charges have gone up. Since the service was introduced by the previous Minister for Health, the late President Childers, go ndéanna Dia trócaire ar a anam, the cost of the scheme has increased from 1971 when it was £63 million to over £120 million this year. I feel that the people who are asked to pay these contributions will not object and I believe people are sufficiently well aware of the situation nowadays to realise that they cannot expect to receive a good service unless the contributions they are asked to pay and the cost of the services go up all the time. It is something which we must not dramatise and certainly not in any way that could be regarded as injurious to the morale of the people who are so unselfishly providing the very fine professional services we have.

I should like also to mention the matter of community care. This is a theme which the Minister has on many occasions spoken of and encouraged. I think there should be a concerted effort between the Department, the health boards and the county councils to step up on community care and a very determined policy to erect a number of maisonettes, chalets or flatlets on the ground floor, adjacent to our district hospitals, and to extend this kind of care that we have here in a number of private institutions in and around the city of Dublin, so that elderly people can have a flat, living outside of a hospital or a home, and having a common diningroom where they can get for their weekly contribution a solid mid-day meal and fend for themselves for breakfast and supper, in addition to being looked after by the professional staff in the hospital, convent or home. We should try to extend this kind of service to every town where we have either a county or a district hospital. It would be a great advance in community care. It would bring elderly and slightly incapacitated people into care in a semi-community way, giving them the independence of their own home, with the advantage of, perhaps, releasing more houses for newly-married people and houses which some of the older people do not feel able to continue to run.

I ask the Government seriously to consider extending this type of service which has proved to be so valuable in the private sector at present, and there are a number of very wonderful places of this type in Dublin and we ought to try to have our county councils operate something on similar lines. The older people wish to retain their own hearth and home and we should make a big effort to meet this trait in the Irish character. I do not think it would be all that costly because a nice flatlet for a single elderly person would not cost so much and would be quite easy to maintain and there is no reason why it could not be very well operated in conjunction with our district hospitals in many parts of the country. In this sphere as well, unlike the retirement villages or cities or homes which one finds in Miami, it would be a small community which would be quite a breakthrough in the care of the old, leaving them their independence and at the same time giving them the care and comfort they have earned down the years.

I was quite amused by some of Deputy Collins's contribution but I join in his tribute to the junior doctors. I am glad to note that he is a convert, even if a late convert, to the recognition of the wonderful contribution which these young people are making to the hospital service. I am sorry he did not recognise that contribution earlier when he was in power and in a position to do so.

I should like to mention also the facilities in relation to mental health and the strides and progress made over the past number of years. In this field we have a service which everyone, whether taxpayer or ratepayer, can be justly proud of, although it is something which we seem to pass by and fail to notice, but in every community there are people who are motivated to give of their time, their energy and, perhaps, financially, to show their desire to help people who are afflicted with mental handicap. This is something we must recognise and I wish to compliment the Minister and the Department for the encouragement they are giving in this sphere but there is, nevertheless, some leeway to be made up. We need more beds for severely handicapped children.

I do not know if the Department have been looking at the progress made in the care for mentally handicapped in parts of the United States. There the wheel seems to have come full circle. They have progressed further than we have but they now seem to be back almost where they started in their thinking with regard to day centres or institutional care. I compliment the Government on the concessions given by way of income tax to those with handicapped children. As taxpayers, we should encourage the Government to continue this kind of aid to those burdened with what is a very heavy cross in many instances. Unless one is closely associated with such organisations as the Friends of the Mentally Handicapped one does not appreciate the scope of the problem or the magnificent work done by voluntary organisation.

I take this opportunity of complimenting the Minister and his Department on the progress made this year in Europe. I am very happy about it. I and my colleagues in the European Parliament played a role in having projects such as the provision of sheltered workshops and facilities for training the mentally and physically handicapped included in the European Social Fund. This was a considerable achievement. It seems to have passed unnoticed here even though we stand to gain. I believe some institutions have already received considerable benefit from this social fund. I take this opportunity, too, of thanking the Minister and his Department for the briefs and information so readily made available to me when I asked for them early in the spring. We succeeded in making this breakthrough. Heretofore money spent on retraining could only be spent on those from whom an economic return could be guaranteed. I am very glad we had the opportunity of bringing our Christian principles into social thinking in Europe. Where materialistic social policies were the order of the day there is now a new spirit of social concern. Even though we are a small country we have a great deal to offer because of our democratic background. It is difficult to appreciate this until one experiences a somewhat different approach and finds oneself co-operating with people who have not quite the same respect, perhaps for democracy. Despite certain drawbacks, we have here a more democratic society and a greater respect for democratic institutions than will be found in any other country. It is an experience to come up against the different systems and it is an achievement to be able to introduce Christian thinking and social theories and have them accepted.

The Minister might give us some information on progress in regard to mutual recognition of diplomas and degrees in the medical sphere. There is a commission sitting on this somewhere in Europe and its work should be of great interest to many of our people. We have a tradition here, well recognised and appreciated, of producing a very fine type of professional medical personnel, imbued with Christian social medical ethics, and it is important that our degrees and diplomas should be recognised in the other eight member States of the community. Here it takes two years longer for an undergraduate to become a doctor than it does in some European countries. The Department should insist on our retaining the very high standards with which we have been credited. Indeed, the aim should be to increase the quality of the training and education.

Over the last few years considerable difficulty has been experienced in finding places for student nurses. The victims seem to be young girls who have got their leaving certificates a year ahead of schedule. They go in for children's nursing and, having done that course—I see the Leas-Cheann Chomhairle looking at me——

An Leas-Cheann Comhairle

I am getting a little worried.

Mr. McDonald

Those who contribute to the health services should have the benefit of qualified nurses. It is very difficult for these young nurses who qualify as children's nurses to transfer subsequently to a general training hospital. I would ask the Minister to devise some scheme under which these people could get some kind of priority.

An Leas-Cheann Comhairle

The Deputy is straying from the scope of the Bill before the House.

Mr. Corish

He is no worse than those who went before him.

Mr. Tunney

No worse? We would expect a lot better from that side.

Mr. Dowling

These Europeans should be far in advance of us.

Mr. McDonald

The Bill is very small and it is hard to stay on the straight and narrow path, but I will do my best. Part of this money is being spent on hospital in-patient and out-patient services. A few weeks ago there were sizeable headlines in the paper about a GP who earned a considerable salary last year. Ordinary people like myself down the country jumped to the conclusion that all GPs are in this category and, being true Irishmen, we lacerated him from head to foot. In the rural areas an effort should be made to encourage GPs who give an excellent service—most of them are overworked and find great difficulty in keeping abreast of their work—to organise group practices. If at least two doctors were working together, one could work one night on, or one week on, as the case might be, and he could look forward to a number of nights, or a number of weeks, when he would not have to answer the telephone or the door.

Many doctors are grossly overworked and this must be a considerable strain on them. I know there are many general practitioners in group practices but, in the less densely populated areas, this is not very practical. We must ensure that there is a reasonable service available especially at weekends and at night in the rural areas. I should imagine that it is easier to organise a group practice in the city and in the urban areas. In my own locality these people have to work very long and ardous hours.

Under this Bill people are entitled to these out-patient services. The Minister might consider asking the health boards to provide more public health nurses. We cannot be always looking at the cost of the services. It is more important that our people should be well looked after and well cared for. Most people abhor the thought of extra taxation or extra contributions, as we heard tonight but when a patient, whether he be young or old, is lying on the broad of his back what he wants is a good service. We are all the same and we tend to recover more quickly if we know we are getting a good service and that payment for the service will not present a problem when we have recovered.

I support this Bill. I do not see any reason for some of the outlandish criticisms which were levelled against the Minister and his Department and against the doctors and the hospital services in general. This is an error we should not allow ourselves to fall into. Most Irish people do their best, irrespective of their station in life. It is an Irish trait to look at everything from a negative point of view. I do not wish to lecture my colleagues on the other side of the House. I am as Irish as they are and I suppose I have the same tendencies.

I wish the Minister well and I hope the services his Department provide will continue to develop and progress. I hope we will be able to keep up the momentum and keep up the high standard to which our people are growing accustomed. Great credit is due not only to the Minister but to his predecessors and to successive Irish Governments who have given our people such good service and such good value for money.

I have not made up my mind on the contribution the health boards have made. I know the expenditure on health in my own county. I was on the county council for 16 years before the health boards were introduced. I do not think there are any extra doctors or nurses in my county. The administrative staff have been increased. There is a new staff in the headquarters for the region in Tullamore. Perhaps it is necessary to have a big administrative section now organising a comprehensive health service, but I would prefer to see a greater proportion of the money being paid to professional people to help those who are ill. I hope there will not be a further escalation of administrative staff. Perhaps I am being like the type of Irishman I mentioned a few minutes ago. We must recognise the fact that our health services are second to none and can stand comparison with the services in any country we have the honour to work with in Europe.

Mr. Dowling

I listened with great interest to the previous speakers. Deputy Bermingham summed up the situation by saying that this Bill is about the contrbutions. Bascally, that is what it is. It falls far short of what we would desire. It is a fleecing operation. Possibly if the Minister were on this side of the House he would call it a mini-budget. It has been called many things in the course of ths debate. It is a means of extracting further money from the hard-pressed sections of the community.

This is an ever-changing world and people are demanding additional and better medical services. It costs more money to provide these services but the people are confused by the statements made in relation to them. They have been told that there is a free health service but they do not know what the health services are about. They do not know if the service is free or not.

After this debate the people will know that the health services are not free and that more money will be extracted from them. This is a budget in itself but it is not a very honourable way to do things although we have almost become accustomed to this method. This is the fourth increase pushed upon us in the last week. The Minister has been given credit for indicating to the House that he required this money and for not using the backdoor method adopted by the Minister for Finance in relation to the petrol situation but it is still a further extraction of finance from the people. It appears that the Government need a large transfusion of cash and every device is being used in order to extract it from the people.

The present Minister has made many improvements in the health service and I applaud all his efforts because the improvements are necessary and desirable to keep pace with the general trend and the greater demands of a more civilised society. I should like to pay a special tribute to some of the hospital authorities for the excellent service they provide. Some of them have been criticised and there is no doubt that some are deserving of criticism. I should like to pay tribute to the staff of St. James's Hospital in Dublin. For a number of months prior to his death my father was a patient in this hospital. He was a very old man but, nevertheless, he received excellent treatment from a wonderful staff. I want to discount the criticisms about the treatment of old people in this hospital.

I had a similar experience in Cashel hospital. The old people there are well looked after by a very efficient staff. Anybody who has a parent in need of hospitalisation need have no fear if that parent is sent to St. James's or Cashel hospital. To the staff of these hospitals I extend my appreciation. During the by-election campaign in Cork I had occasion to visit the hospital in Fermoy and I was saddened to see the condition of that hospital which caters for old people. That hospital is no credit to any Government or to any of us but I will not single out the present Minister for criticism in this respect. My visits there left a sad impression on my mind.

Where old people are concerned I hope that an active and determined effort will be made to ensure that the people who made such a great contribution to this State will be able to end their days in relative comfort and are given the attention and treatment they deserve. I am not saying that the treatment administered to those in Fermoy hospital was bad but the condition of the hospital was not good. The same applies to some of the hospitals I visited as a member of various boards. Some hospitals where old people are patients are fire traps and fire-hazards.

With parrot-like precision the Minister used the expression that has been hackneyed through the House for a considerable period, "the House is aware of the current world economic situation which threatens all economies with recession of major proportions". The current world situation seems to be responsible for everything. I do not know how the Minister for Finance will attribute the increase in dog licences announced today to the world situation but I am sure he will find a way around that. We are told that every problem has been brought about by the current world situation.

As Deputy O'Malley indicated, this Bill falls far short of what we require. The deception in the introduction of it, the extraction from the people of the finance, particularly those who were hard hit in the past and are in for a tougher time in the future, is to be deplored. The limits for medical cards were set 12 months ago when quite a number of people did not qualify. However, we see in this evening's newspapers from the consumer price index that the cost of living has gone up by 20 per cent between November, 1973 and November, 1974. Because of this steep increase in the cost of living quite a number of people are now entitled to medical cards but they are debarred because the limit was set 12 months ago. In my view the cost of living index should be a factor in bringing people within the scope of this scheme.

The Minister did not indicate that an immediate revision would take place but there are changing circumstances. Much of the increase in the cost of living can be attributed to the Government. They had a misleading effect on the public 20 months ago and I do not think we deserve the type of Government we have got. I hope the Minister will endeavour to tie the limits for medical cards to the cost of living so as to ensure that those who are entitled to these services are not deprived of them.

There has been a lot of talk about the failure of the Minister to reach agreement with the doctors and we have been told that we may be able to have the extended medical service when agreement is reached. The question of agreement between trade unions and employers is an ongoing problem. Agreements have to be reached. One sits down and tackles the problem and, if one is really sincere about one's concern, one remains until such time as agreement is reached. Why should some people have to suffer indefinitely because of a failure to reach agreement? The Minister has a positive responsibility in this respect to pursue finality of agreement as quickly as possible with the people with whom it would appear he is in dispute.

The people are quite certain now that the free health services about which they were told are not free, that there is nothing free about them. But they are entitled to the services they were promised. Were this an industrial dispute or one of another nature, one would have to sit down and work out a solution acceptable to all parties. I do not think that beyond the limit of the capabilities of the Minister. There are two sides or points of view to be taken into account in any dispute and their respective problems must be examined, analysed and agreement reached suitable to both sides.

If the cost of living spiral is maintained at its present rate there is no doubt that additional hospital and medical services will be required for the many people who will be suffering from malnutrition for want of foodstuffs the price of which, as the papers point out, have increased very substantially over the past 12 months. If people are unable to obtain food, they will be very prone to sickness and then the question of provision of medical services is a very real one indeed.

If this Bill is an example of socialism in the seventies, then I am glad I am not a socialist because I, and the members of my party, feel that this type of Bill is far short of what is required today, apart altogether from the backdoor method of extraction of the finances.

A point has been made about the insistence of the Voluntary Health Insurance Board on a 24-hour stay in a hospital which takes up many beds perhaps needed for urgent cases. These beds are taken up by people who in the ordinary way could remain in their own homes but who are compelled to go into hospital because payments will not be made to them unless they remain there for a 24 hour period. These beds are now known as the beds with the golden legs. The only outlay on those beds is the clean pair of sheets used each day in respect of which the hospitals receive a substantial return. These beds are required from time to time by people in distress who need to be accommodated in hospital but who are unable to obtain beds.

I hope a change will take place in this respect whereby people, so insured, can get a service and be maintained in their own homes without taking up necessary beds and depriving the more needy section of the community of the medical services to which they are entitled. It is the weaker section of the community about which I am concerned. I am not terribly concerned about the man who can pay for his own medical services. But he must be able to obtain such services. No doubt there are people at present who can afford to pay but who are still unable to obtain medical services because of the present situation. I hope this will be remedied in the future and that we will have a type of service which will provide for the necessities of the people in need of medical attention. This insistence by the Voluntary Health Insurance Board that people remain in hospital for a 24-hour period deprives the weaker sections of the community of much-needed beds and discriminates against them. This is something that must receive serious and immediate attention.

I listened here yesterday to Deputy Coughlan. I am sure the Minister was just as disgusted as I was at some of the remarks he made. Deputy Coughlan spoke about the mid-west. One would have thought he was in the wild west listening to him and to the various remarks he made. Certainly they were not the remarks of what could be regarded as a normal, sane man. It is possible that Deputy Coughlan needs medical attention because it would appear to me, and to many other people here yesterday listening to him, that he was a man in need of immediate medical attention. He made a number of references, particularly in relation to doctors, that if one were to examine doctors' accounts it might reveal something substantial. This type of reflection on the medical profession, who are giving valuable service to the community, is one over which nobody could stand. It might well be that some particular doctor abuses the situation. But if Deputy Coughlan is aware of such abuse when he speaks in this House and infers that a revealing situation would be thrown open if doctors' accounts were examined, then he should come forward and correct the situation. We have an obligation to ensure that where people seem to be carrying on sharp practices in some form or other, they be properly exposed.

But to cast a reflection on the entire medical profession is entirely wrong because the public at large might be tempted to point to every medical practitioner and say "Is it he?" Deputy Coughlan must be made to indicate clearly the people concerned in this sharp practice, if in fact they are so concerned. Such remarks are unfair to that responsible section of the community doing such excellent work, sometimes in very difficult conditions, very irregular hours, resulting in a disruption of their home lives and being called out at all times. Possibly the demands made on them are greater than those made on us because of the uncertainty of their hours of rest. I do hope that on the next occasion on which Deputy Coughlan comes into the House he will either, as it was put today, "put up or shut up" because I think it wrong that people be vilified in the manner in which Deputy Coughlan vilified the medical profession yesterday. They are honourable men, and if there is one amongst them who is carrying on some type of sharp practice then the whole group of them should not be suspect. I would appeal again to the Minister to extract from Deputy Coughlan, privately or otherwise, the information he alleged he had here yesterday in his wild west speech.

I shall not delay the House much longer. I appreciated the views expressed by many Members here, forthright and honest views expressed, whether by Members of my own party or by Members of the Government parties. I was glad to hear a colleague of mine, Deputy Dr. O'Connell, being very forceful here yesterday, indicating his views in very clear terms.

If a supporter of the Government expresses dissatisfaction with the situation, one can hardly blame us for expressing our total dissatisfaction. Deputy O'Connell's approach to the problem was very honest. It would have been better if the entire debate had been approached on that basis because in that way the Minister, or any Minister at any time, would become more aware of the real problems affecting the ordinary people, those who constitute the majority of our population. In Dublin some people on re-applying for medical cards have been informed that they are no longer eligible. These decisions have been reached without account being taken of the 20 per cent increase that has occurred in the cost of living.

The Government have raided the housewife's purse. They have done the same to the motorist. We can only hope that advantage will not be taken of the Recess to indulge further in tactics of this nature. Our complaint concerns the deceptive way in which these extractions have been imposed. However earnest the Minister may be, we cannot support him. The situation here arose, I presume, as a result of a Cabinet meeting at which he was pushed into the situation. I consider the Minister to have some semblance of socialism, but the approach here has no element of socialism; or at least, if it is socialism, my socialist principles are far greater than what I understood them to be because this measure is far short of what is required. We can rest assured that, given the opportunity, the public will express their dissatisfaction with the Minister and his colleagues.

During a debate on another topic last evening the Minister for Agriculture and Fisheries saw fit to introduce some matters pertaining to health. We are wondering whether he consulted with the Department of Health in regard to the quality of certain foodstuffs and whether there is a necessity for people in the interest of their health to reduce their consumption of butter. The Minister seemed to suggest that the people would be much healthier if they consumed less butter. We would like to know if it is the policy of the Department of Health to encourage reduced consumption of butter. This is an important question because it relates to a wide area of health.

The Minister can be assured of the support of this side of the House in any contribution he may make towards a better health service for all. He has made some contribution in this area. We appreciate this, but the ever-changing circumstances of our time demand constant progress so as to keep us abreast of any new developments in drugs, techniques and so on. The Minister for Health at any time has a duty to ensure that the health services are kept up to date. We are aware that there is the question of finance, but it is the method of extraction with which we disagree.

Mr. Hegarty

I wish to make merely a few points in relation to this Bill. First, I compliment the Minister on the excellent job he has been doing in the Department at what can be regarded as a very demanding time. Our health services are excellent. That is not to say that we should be satisfied with them. Nothing is ever perfect, so we should strive always towards improvement. That is what the Minister is doing. Perhaps the reason for any delays that may occur is that the Minister is taking his time so that he can have available to him all the advice possible to help reach the right decisions. However, I would make a special appeal to him in respect of Mallow hospital. I trust that the right decision in that regard will be reached as soon as possible.

The contributions being asked for in respect of the health services are not significant. If possible, I should like to see the general medical services scheme being extended. Of course we must realise that nothing is free: in the final analysis everying must be paid for. It is difficult to adjudicate who is entitled to medical cards, because what applies in one case might be irrelevant in another. In other words, there is need for more flexibility in the system. A man whose children need regular medical attention can be in a very difficult position in so far as paying doctors' fees is concerned. It is not enough in such a case that the only concession would be free drugs because the doctor's fees could be a real burden.

Perhaps the criteria applied in respect of applications for medical cards is not as strict in all areas but I have made representations in respect of what I considered to be very deserving cases only to be told that the people concerned did not qualify. I wish to register my protest at the inflexibility of the method of determining qualification. There was one case in my area of a pensioner whose wife was neurotic so that she required a doctor very often. Admittedly, the combined pension of the man and his wife was greater than the income limit laid down for qualification for a medical card.

This man has been refused a medical card for his wife. The very fact of having a medical card would probably mean that he would not call in the doctor at all. I know this is a very unusual case but this is the sort of instance that should and must be met. If the whole system of medical cards could be extended to embrace a much wider section, again with some contribution, I am sure the people in the higher income bracket would not object to a little more for this insulation of having a medical card when needed.

I should like to praise the doctors and nurses for what they are doing in the various hospitals. I should like to see an extension of the district nurse service. Much of the load would be taken off the GP if we had many more of these excellent nurses. They are really doctors in themselves. They do fantastic work, but we have not nearly enough of them.

In that connection, I should like to appeal to the Tánaiste and Minister for Health to have more and more young girls trained. Every year we have this set-up at St. Finbarr's Hospital in Cork—I am sure it is the same everywhere—where they can accept only 50 applicants out of about 1,500 girls attempting to enter the profession. We should give these girls an opportunity of devoting their lives to this worthy profession. They should not have to go abroad to be trained. They come to us as public representatives to see what we can do. Getting into these hospitals is nearly like winning the sweep. Something must be done in this regard and quickly, and the health services generally will boom as a result.

I have reservation about giving permanency to married nurses. I do not think this is such a great idea. When they were kept on in a temporary capacity I think they were happy enough. These interviews that are taking place for permanency are causing confusion and disturbance, with single girls who have been nursing for a number of years being told they will not qualify for permanency, that they did not succeed at the interview; yet nobody found fault with their performance of their duties.

I would appeal to the Minister to make more money available in respect of geriatric patients in private hospitals. I have in mind the Bon Secours Hospital in Cobh where the nuns are doing great work, and what they are getting for these patients is a mere pittance.

The previous speaker mentioned flatlets. That is a great idea and should be extended to the public sector where old people would have the best of both worlds: they would have some privacy and the expertise needed for old people, especially old people who have nobody to look after them. We should not be in such a hurry to push our old people into homes. One of the criticisms of this modern age is that we are too much inclined to hand over our parents and our old people to the care of the State. When old people became ill and needed a lot of care, this care was always provided in the Irish home. We have that responsibility and if we are Christians we will not try to pawn them off on the State.

I should like to compliment the Minister and the Parliamentary Secretary, who is from my own constituency, on the performance of a very difficult task. Their life would be much easier if they had the wherewithal to do all the things necessary, but within the limits of their resources —and we must be honest and recognise the resources are limited—they are doing fantastic work. They both work very hard. Good work was also done by previous Ministers. Reference was made tonight to the late Erskine Childers. He, too, was a great man, but he has been succeeded by an equally good man in the Tánaiste and Minister for Health. He probably inherited many of the problems, but I am not saying the problems were not dealt with—the problems are continually growing and will always be great in this field because there are more and more demands as society becomes more sophisticated. However, I am confident the Minister will deal with them and continue to give the good service he is giving. The fruit of the Minister's work and of his decisions will not show up immediately. When he gets down to the problem of upgrading hospitals and deciding in a logical and businesslike way where they are to be put, it is then we should all see the wisdom of his decisions.

As I promised I would not detain the House very long, I shall conclude by thanking the Minister and hoping he will be spared for many a day.

Mr. Hussey

It is unfortunate in the present economic situation—at a time when our people are faced every other day with increased costs for foodstuffs and everything else—that this Bill should propose an increase in contributions under the Health Act from £7 to £12. It has one good effect, that at least it gives the House the opportunity of discussing some aspects of the health services which we Deputies did not have an opportunity of doing heretofore. Health is something that interests all of us. Whether we are doctors, lay men, TDs or whatever else, we are all involved in the health services. We are all involved in endeavouring to provide the best possible service for our people.

Will this Bill have the desired effect of raising the contributions by £3½ million? My experience has shown that even when the contributions were only £7 a year and times were better, the health boards found it very difficult to collect this annual sum. In recent months I have seen bills going back over three years which were sent for payment. Apparently the people have not paid their fees for that time and were confronted with bills for £21. If it was difficult to collect £7 a year, I dread to think what it will be like, in the present economic situation, trying to collect £12 a year. Everybody, particularly the farming community, has been very hard pressed for the past 12 months. Many people thought that perhaps they were entitled to a medical card. They could not be blamed for exploring every avenue to get the medical cards. When the health boards found that they were not entitled to a medical card, bills were sent for £7 or in some cases £14 or even £21.

I do not know if the health boards have made any serious efforts to collect these bills. To my knowledge nobody has been brought to court or received a solicitor's letter. People merely got a notice from the health board indicating the amount due and asking that it be paid forthwith. In many cases those notices have been ignored.

No matter what objections we raise to the increasing of this amount, I realise that eventually it will be brought into law by the vote of the Coalition Parties. That being so, all I can do is indicate where I would like to see this money spent.

Many suggestions have been made to improve our health services. One of the biggest problems today is the patients in long-staying hospitals, that is, geriatric, psychiatric and mentally handicapped. The programme for the replacement of the psychiatric hospitals has a long way to go. The policy of erecting welfare homes should be speeded up as much as possible. As resources permit we should reduce the overcrowding in our county homes and psychiatric hospitals. We should also remove from the latter the geriatric patients who should never have been accommodated there.

I compliment the Western Health Board, and in particular the CEO, Mr. Hannon, for the wonderful work they have done in trying to provide homes for our elderly citizens. They have devoted themselves to this problem and deserve our full support and congratulations on their achievements to date. The following accommodation is available in the county: in St. Brendan's Home, Loughrea, they have 350 beds; in Merlin Park Hospital, 150 beds; St. Anne's Home, Clifden, 42 beds. This gives a total existing accommodation of 542 beds. They also have public projects planned: a home for the aged at Newcastle, Galway, 40 beds, the foundation stone of which was laid on 30th September, 1974; a home for the aged at Carraroe, advertised for tender, 40 beds; a home for the aged in Galway city, in Tuam, Ballinasloe and Loughrea, 160 beds. This makes a total provided and planned of 782 beds. They also propose to set up a geriatric assessment unit in Merlin Park. The physician/geriatrician who has been appointed by the board will be taking up duty on 1st January, 1975. This is a great achievement by a board who have been in existence for such a short time. I admit that there is still room for further improvement.

As I said before, one of our main problems is the provision of accommodation for our elderly citizens. Our existing homes are very overcrowded. In addition to the overcrowding of our psychiatric hospitals, which makes it very difficult for nursing and other medical staffs, there is also the serious problem of our adult mentally handicapped. In that respect I welcome the announcement made on 14th December, 1973, at Brigid's Hospital, Ballinasloe, where the Parliamentary Secretary to the Minister for Health stated that he had approved the provision of separate additional accommodation outside the psychiatric hospitals for the adult mentally handicapped. This announcement did not come one day too soon. I request that the proposals already with the Minister in this regard be approved as speedily as possible.

There is still the very serious burden of handicapped children. The efforts of voluntary organisations deserve greater support from the health boards and the Minister for Health. They are to be commended on the tremendous work they have been doing down through the years for these children. I am of the opinion that each health board should have their own director for the mentally handicapped. Otherwise it will be impossible to provide an adequate service. It would be wonderful if there was one person to co-ordinate and be responsible for all the services. In that way we would get better results from the voluntary organisations and others involved in providing this service.

The dental services are the Cinderella of the health services. There seems to have been a slight improvement in the recruitment of staffs in recent years but the service is still not nearly as good as I would like. At present those people are confined to or they are taken up largely looking after children, expectant mothers and so forth, who hold medical cards. This is one service that calls for improvement and I ask the Minister seriously to consider proposals made by the Western Health Board in this respect.

They propose that the board be allowed to engage the services of private dentists. I agree with this proposal because if it were accepted and if private dentists were engaged at the same scale of fees as dentists are paid for the treatment of adults under the social insurance scheme—I see no problem in that respect: I do not see any difficulty for the Minister to pay dentists the same fees for looking after medical card holders as they are paid for treating people insured under the social insurance scheme—it would help to relieve the backlog of applicants for dental treatment. There is a terrible backlog and unless something like this is done I can see no easy way of eliminating the long list of people waiting for dentures and extractions. It should not be a great problem for the Minister to balance these things out, particularly as he holds the double portfolio of Health and Social Welfare.

In recent years there has been a serious shortage of public health medical staff caused by retirement. Because of this the school medical service has not been maintained, not to speak of being improved. This scarcity of medical staff can only be eased by improvement of the system for recruiting doctors, and the best incentive towards this is adequate salaries and job satisfaction. This service is one of the most important of all from the point of view of expenditure on health services, yet it is more noteworthy for its decline rather than its development. It is an unfortunate situation because it is vital that children should be examined and their health properly looked after.

District nurses scattered all over the rural areas are doing a great job. However, they are hampered by scarcity of numbers. The ratio of nurses to patients—4,000 per nurse— permitted by the Department is far too high. Particularly in rural areas, difficulties are encountered because of bad communications, difficult terrain and sparseness of population. I suggest that the ratio of population per nurse should be reduced. Not alone would it be good from the point of view of health service costs—it would keep people out of hospitals—but it is good socially. The best way to achieve this is to provide an adequate staff of nurses. We are all anxious that people be kept out of hospitals and where possible treated in their homes. At present many of those who are in hospitals should not be there and they would not be there if we had an adequate district nursing service.

I would draw the Minister's attention to the apparent conflict between people covered by Voluntary Health Insurance and others. Deputy O'Malley said the other day that one of the requirements under the voluntary health scheme is that a patient should spend at least 24 hours in hospital. I agree that this is wrong because it is contributing to hospital overcrowding. The Health boards and the Department are concerned with keeping people at home where possible. Here we have the Voluntary Health Board encouraging people to go into hospitals. This is something that should be looked into.

In most health board areas there is a shortage of physiotherapists, social workers of different kinds, occupational therapists and speech therapists. An effort should be made by the Department to make such staff available where they are required. I see no reason why patients in Galway or Roscommon or elsewhere in the west should have to travel to Dublin to get specialist service. Such services should be available in the regional hospital in Galway and in the other health board areas. This would eliminate the necessity to bring patients by ambulance or helicopter to Dublin or to Cork, in that way subjecting them to the rigours of travel and making it difficult for their relatives to visit them.

One problem I have heard people mention is in regard to operations for brain haemorrhage or brain tumor. Apparently such operations cannot be done in Galway and most of our patients have to be transferred either to Dublin or Cork. Again, this causes hardship for the patients and their families from the point of view of visiting.

We have heard a lot recently about alcoholism and its effects on young people. It is time the Department of Health did something constructive about it because it has been left more or less to Alcoholics Anonymous and other such bodies to highlight its terrible effects. It was only recently that it was brought home to us by the bishops when they devoted one Sunday to temperance. They outlined the amount of money that is being spent on alcohol and the damage it was doing to young people. We should all be involved in trying to remedy this problem but the lead should be given by the Department through advertising on television and radio the dangers to young people of alcohol. Publicans, too, should be exhorted to keep within the rules and not to serve drink to anybody under the age of 18.

Mr. Moore

The maintenance of good health services is the most basic need in society. I agree with Deputy McDonald that we have fairly good health services. This is due to the fact that during the years we have had dedicated Ministers for Health. The present Minister is playing his part in trying to improve the service, but he is being very much hampered by lack of money from the Government and by general apathy, from the Government point of view, in regard to his efforts. One can say that, despite the advance to the present state of our health services, a great amount of work must still be done before we could be satisfied that even the weakest person in our society is assured of treatment, hospitalisation, or outpatient or medicinal treatment. We are not happy with the present position.

Under this Bill added taxation is being imposed and it may well mean that in paying this extra money many a person will have to deny himself some delicacy or something he likes. While they will subscribe to the State's scheme of medicine they may be affecting their health through being deprived, perhaps, of some food when they find that the taxation which is now increasing weekly is almost unbearable. I want to make the plea that the Department of Health should probe the various categories of our society and not just accept that because somebody lives in a suburban area and may appear to have a fairly high standard of living he is all right but to realise that behind that facade there often lies dire poverty and that we must shape our health services to cover such people.

We must take to task the Government and the Minister for their attitude regarding the issue of medical cards. It may be said that this is a matter for the health boards, in this case the Eastern Health Board, but that is only half the story, because if a direction goes out to cut down on health services so as to save money the medical cards will be affected.

Over the years we could have done much more to keep people out of hospitals rather than to drive them into hospitals. Today, with improved housing standards, the vast majority of houses in the city have hot and cold running water and I suggest that minor operations could be performed in people's homes. This would have a big social benefit. For example, where a mother may need a minor operation, instead of taking her away from her children into hospital, that operation could be carried out at her home, allowing her to remain with the children and also reducing the heavy cost of hospitalisation.

With the end of the dispensary service I felt that we might well have used the dispensary buildings for mobile teams of nurses, physicians and surgeons who could go out to people's homes where the treatment required was essential but not serious enough to entail hospitalisation. The example is there in the maternity hospitals in Dublin. They are, and have been, operating a mobile service for years which is very efficient. The comfort it would bring to a woman with any sort of psychological problem would be enormous if she knew that a mobile team could be at her house within minutes of her doctor requesting them. Why can this principle not be extended to other branches of surgery instead of sending everybody to hospital where it costs a fabulous amount even for a week? Why could the home not be used as a base and so allow the mother, or the father, to stay there?

This is not cheese paring. This idea was put forward by a famous English doctor some years ago. It has been followed in this city to some extent and put into practice. But I want to see it used on a much wider scale because, apart from anything else, we can save a good deal of money on it which would help to prevent extra taxation on people who find it difficult to meet the present burden.

If one requires treatment at the Dublin Eye and Ear Hospital one must wait months for a bed. Only tonight an old lady with a cataract on one eye came to see me. She is to have an operation in the hospital but she must wait until next March before they can take her in. That is no reflection on the staff of the hospital or the authorities, but we have a grave shortage of beds. It is fair to say that this is no recent development; it has existed for years. Admittedly, the delay has been reduced, but here we have a case in December where an old lady must wait until March before she can have her operation. This is quite wrong. We cannot boast of our health services until that type of grievance is removed when a person whose vital faculties are affected must wait months for treatment. I hope the Minister in replying will give us some hope that the waiting period will be cut down. Especially in the case of old people, life with bad eyesight must be a misery and they should not have to wait and worry. This old lady, who lives alone, must worry all the time over the delay and in the end she will have to face the ordeal of the operation.

This is one sector of our hospital service which demands investigation. If it is shortage of skilled personnel or beds or buildings we should tackle the problem as it is a basic blot on the health service. It would make taxation more palatable if the service was adequate but we shall pay the extra taxation and still have people waiting many months for admission for treatment. This may apply to other branches of surgery—I do not know— but I can assure the Minister that the case I have quoted is genuine and I can supply details if he wishes. I am sure he gets similar cases from Deputies and from people in his own constituency and on a national basis. The Minister who will be able to have it recorded against his name that he cut down the waiting queues for eye treatment will need no other monument to his memory.

Debate adjourned.

Dáil Éireann debate - Thursday, 12 Dec 1974