I was referring to changes in conditions that have taken place in health work and the extension of services with special reference to the fact that we have ENT services, orthopaedic services, maternity and paediatric services now which were not available to us when I began to practise medicine. I said the life of the doctor had changed somewhat also, because maternity services are now mostly provided in hospitals thus not imposing on a doctor's time to the same extent as in the past. We now have much more time off. This became available some years ago and it has made a doctor's life somewhat easier.
There are still pressures on those in general practice and whatever incomes we get we have to earn them reasonably hard and we must work fairly long hours. There is also the pressure of the standard of medicine now available. We must be more aware of what is happening, of how diagnoses are made, of the treatment available for them. This means we must be better educated.
A doctor's education is probably available to him from four or five sources at present: first, from his experience; second, from what reading he can do. A doctor has not much organised time for reading because, with the best intentions, he may decide to study an article but the slightest interruption is likely to put an end to that study. The third— and a very important source—is the information fed back to him from the consultants to whom he sends his patients. Most of these consultants are very conscious of the work they are doing and have done and generally they try to make this available in detail to the general practitioner. Unfortunately, this is sometimes delayed and I would urge the Minister and the Department to ensure that the consultants have available whatever clerical staff they may need or whatever facilities they may require to get those reports out quickly in a form acceptable to them.
The fourth source of education is the more formal education of post-graduate type whether it be obtained by taking time off or by time being made available for post-graduate courses. All this adds up to the doctor being more efficient and making his services much more beneficial to those he attends.
Another pressure has been removed from the general practitioner by the introduction of the fee for service. It cannot be gainsaid that the ideal type of medicine would be where a patient could make a direct payment to a doctor for the services he gives. This ideal obviously cannot be attained in our present society and we must do with something else. The fee for service is a system that is acceptable to me and to many of my colleagues. Some do not agree with this; in the past there were very many more, but I never had any particular objection to State medicine within reason.
In the past, with the medical card system, doctors found themselves in the frustrating position of having to carry an extra work-load without any financial compensation. This is not so with the present system; a doctor is paid for any additional work he does. In spite of all those improvements there are black spots and, as far as I am concerned, a few very black spots. When Deputy Haughey had a motion in Private Members' Time recently I had a few minutes to say to the Minister that there was a grave obligation on him to try to remedy those black spots. I referred to the dental services and the ophthalmic services which are anything but satisfactory. The waiting list is too long. This is a priority service and should be dealt with immediately.
In his introductory statement the Minister said:
We must carefully look at the resources available for health care.
Later he said:
This is a problem of correct allocation of human and financial resources to meet the needs of the future.
He also spoke of making the best use of additional resources in order to improve the health of our people. This is one of the most important health areas which should be improved immediately. Other speakers have mentioned that personnel for this work may be scarce and difficult to obtain and suggested employing private dental practitioners to overcome the difficulties in that regard. I would agree with those people who say that this would help to provide an answer to the problem on the ophthalmic services side.
It must be very frustrating for patients who seek advice regarding dental or sight problems to be told that they are being referred to a clinic but that they must wait for perhaps six, nine or 12 months for this service. It is time that an effort was made to deal with the situation, a situation which arose because in the past dentists were not available to do the work involved and also because more people are in receipt of medical cards now than before. What convinces people most of the need for medical cards is the cost of dentures and spectacles. While they may be prepared within reason to meet other smaller charges, they are not able in many cases to meet the cost of these services and consequently they must seek State aid when they require dentures or spectacles.
Another black spot in the health service is the delay in respect of patients who are referred to consultants. These delays do not arise through any fault of the consultants but because the workload on them is too great. Neither can the administrators of the health services be blamed because, to take my area as an example, at one time we had no orthopaedic surgeon whereas now we have three and an orthopaedic unit as well as three or four paediatricians and three or four specialists in the maternity field. It seems, though, that they are not sufficient personnel to cope with the number of persons being referred to them. This is another area to which State resources should be diverted.
Many changes have taken place in regard to our hospitals. I was the last county surgeon in Roscommon County Hospital—that was the old hospital—and I was the first house surgeon in the new county hospital. At that time there was one senior man at the hospital. He was the county surgeon and he performed all the acute and chronic surgery cases for the county. Also, he undertook a large amount of the medical consulting work as well as the more difficult of the obstetrical work. He carried out all of this work with much interest for his patients but with a lack of consideration for himself and now that he is reaching retirement it is only fair that on behalf of my constituents I should place a tribute to him on the record as a way of expressing their gratitude to him for all he has done for them down through the years. Later he was joined by a county physician, a very well-qualified man who also undertook obstetrics and it was a number of years before he got extra help.
Now we have extended hospital services. There are chest and orthopaedic hospitals and a number of maternity hospitals but we do not seem to have an adequate number of beds. One wonders how all patients can be dealt with eventually. The situation, however, does not seem to be reflected in the figure made available to us because from my experience I doubt the figure of a 90 per cent bed occupancy.
Many Deputies during this debate and on other occasions have referred to the desirability of keeping patients out of hospitals because of the high cost of maintaining them in hospitals. I can think of only one way in which this can be done but my suggestion would involve thinking which, perhaps, would not be acceptable to the Department of Health or to many medical personnel. What I have in mind is to encourage some of those brilliant young men who are studying medicine to train themselves as general diagnosticians rather than embarking on the specialities. We could place them in the county and other hospitals where they would undertake screening work for the general practitioner. They could make the decisions as to whether patients should be referred back to their GP's or whether they should be referred for specialist treatment. This process would remove some of the workload from hospitals as well as enabling people to avail of specialist treatment more speedily than is the present situation. Also, there would be less pressure on specialists.
I do not expect that such a suggestion would be accepted by very many people in the medical profession because the whole tendency seems to be towards specialisation. However, looking back over the years we know that those people who carried the brunt of medicine have been people such as county surgeons and physicians. These people had the wider training and I have no doubt that their work has made and is making a big contribution towards keeping down medical expenses because they are able to channel into the specialist services those cases which must have this specialist treatment.
On the question of bed shortages one must think of the Fitzgerald Report. In regard to our local situation it has been suggested that the County Hospital in Roscommon should cease to be a surgical unit. The Minister has indicated his intention of making some announcement in this regard in the near future. We do not know what he is to say but I cannot see how he or any of his advisers could recommend a reduction in the number of surgical beds there. In the area in which I work I am served by three hospitals, Manorhamilton, Sligo and the County Hospital in Roscommon. Frequently when I seek beds in any of those institutions I am told that none is available. I do not know how we could manage in Roscommon if the acute surgical beds were to be removed. There is no point in suggesting to me, for instance, that my patients could go to Sligo, Ballinasloe or Galway. That would not be the answer. It would only result in overcrowding those other hospitals. In these circumstances the Minister must come to no decision other than one which would leave Roscommon County Hospital a viable unit and staffed as should be any hospital engaging in acute or any other surgery, that is, with, perhaps, two county surgeons.
I do not propose to go into all the arguments which have already been gone into as to why an hospital should be in one place or another, because by and large I appreciate that in the long run people will go to the place where they will get the best service. If the planning people decide that those services will be a long way from them the people will go there but if they do it will be at great inconvenience to themselves, on the one hand, and on the other, at a greater cost to the State. I have no doubt that if hospitals are placed or developed a considerable distance from patients, somebody will be coming into this House in the future asking the State to make transport services available to relatives to enable them to see patients in various places throughout the country, and remember, a first step has been taken in this direction already in that such services are made available to parents to visit handicapped children. Travel will be getting dearer for the health boards and everybody else, and to visit these people in hospital will impose a big financial burden on families and indeed the transport of these people to and from hospital will impose on the health boards too.
Reference has been made to drugs. As far as I am aware, I have no drug problem, except the common one of drink and I join with others in deploring the fact that people seem to be drinking too much, particularly young people. It has been suggested that doctors by holding adult education classes can do something to remedy many of these problems, but I feel that television would probably be a much more adequate medium for doing this. At least it would mean that people would not have to go out at night, leaving their homes and probably profit much more from it.
On the drink aspect there is one remark I should like to make. From time to time we see in the papers or we hear of the occurring of an accident and a doctor was not available to attend. At times such as these, doctors come in for very severe criticism, and indeed at inquests from time to time this happens. Nobody ever goes to the trouble of criticising the person who sold the cause of the accident, too much drink, or criticising the person who caused it for taking too much drink. In my experience, it is true to say this is the cause of 99 per cent of the motor car accidents that I see around me.
On the medicine side, where I work I have the responsibility of dispensing my medicines to the patients and one of the things that strikes me is the difficulty of trying to satisfy patients with a particular medicine, because of the fact that having come back from a hospital or a consultant, when a certain medicine has been prescribed and has been used in the hospital, even though I have available to me the same medicine by a different pharmaceutical company, psychologically in a number of cases this is not satisfactory for the patient. This means that I have to order this extra medicine and find myself in some cases with three different bottles containing the same medicine but all of different colours.
In the past, and I am sure it is so yet, doctors were very jealous of their own right to prescribe whatever drugs they thought best for the patient and were always inclined to resist what they considered to be the arm of bureaucracy interfering in their work. Nevertheless, I feel that something should be done about this. Some effort should be made to standardise the medicines in the Department so that we could get away from this situation. There is no doubt that my suggestion will not be acceptable to the pharmaceutical companies either, but with the growing increase in the number of medicines available for conditions such as blood pressure, chest diseases and heart diseases, it is an aspect of the administration of medicines on both the medical and administrative side that will have to be faced sometime and a definite decision taken on it. It would mean a special list for the purpose and this would create its own difficulties.
Reference was made to the school medical scheme and the Minister is exhorted to have it extended. I have no fault to find with the scheme because it is better than nothing, but I suggest that it be replaced by a pre-school medical examination. In the past, a former Minister for Health invited those of us in the Fianna Fáil Party to make suggestions to him for the improvement of different fields in medicine and I went to the trouble of writing something about the school medical scheme at the time. I have no doubt that at this stage it lies an awful lot deeper in the Department's archives than the document which Deputy O.J. Flanagan has talked about having submitted. Whatever chance his will have of being recovered, I am sure that mine will never be recovered. Nevertheless, I suggested at the time that in addition to the six weeks' examination which infants get now under the maternity services, a further examination be made available at the age of one year and a still further examination at the end of three years. I even went into the detail of suggesting that from the six weeks this be recorded in triplicate, one copy to be sent to the county medical officer of health for permanent reference, another to a consultant if the occasion arose, the family doctor to hold the third. Each examination would be documented, the papers being kept for future reference.
I saw two good reasons why this system of examination should supersede the school medical examination. On the one hand, it meant earlier diagnosis of whatever defect the child might have, with particular reference to teeth and to eyes and indeed to the orthopaedic situation. A further advantage was the fact that children having started school would have most of their health defects dealt with and there would be no need to upset their schooling by taking them out of the school to hospital at various stages and in this way interfering with their education, and particularly would be very important at that point.
I know that there is a pre-school examination scheme being made available in some of the bigger centres but it is not being made available throughout the whole country and it is time this was done. It was said in the past that by having the medical examination in the school it was possible to get around all the children but that is not true because children mostly in need of this examination will not go to school on the day the medical examination is scheduled to take place. A further advantage of what I suggest is that the people who hold the position of assistant medical officers of health would, with training in infant development, infant diseases and paediatrics, be in a position to do further screening of the population submitted to them for examination. In turn this would take pressure off the various paediatric units which are not able to deal with the many problems they face.
This is one of the most exacting specialities because so much time and detail must be gone into and recorded in the interests of the patient. Anything that can be done to take some of this workload off the people doing it at present would be an advantage in the long run to those who need the service most. In his statement the Minister emphasised the attention he intends to give to community care.
