Dáil Éireann debate -
Thursday, 29 May 1975

Vol. 281 No. 7

Vote 49: Health (Resumed).

Debate resumed on the following motion:

That a sum not exceeding £177,022,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1975, for the salaries and expenses of the Office of the Minister for Health (including Oifig na Ard-Cháraitheora), and certain services administered by that Office, including grants to Health Boards, miscellaneous grants, and certain grants-in-aid.

—(Minister for Health.)

Mr. C. Murphy

When I reported progress on the last occasion, I was talking about dental services in general and the backlog which exists. Since then it has come to my notice, and perhaps the Minister could bear me out in this, that schools which are not primary State-aided schools but which are private or junior schools are entitled to benefit under the dental treatment scheme for school children if the manager applies. I was not aware that this was the position but I believe it is so. If this were to arise in certain areas, the system would become further jammed, but it is information which I believe is not fully available. I have had parents in the Greystones area, and who have children attending these private schools, coming to me about the dental health facilities for their children. I believe it is the position that the school manager must make application and the facilities will be provided. This, of course, will add to the great backlog.

The only way in which we can possibly get around that situation is to bring in some more dentists from the private sector and that is worth doing. We are dealing here with our children and their basic requirements. Their dental health is most important. It is wrong that they must suffer after being examined for up to six months before treatment can be given. I know the Minister is aware of this and I will not labour it any further than to express the hope that progress will be made as between the dentists' association and the Department on this fee for item matter.

Speaking in general terms of how I would envisage a hospital, I would see a hospital as being an integral part of the community and I would see it in the context of the overall health of the community it serves and not as some institution apart from the community. I would visualise it as providing the services which people require so that these people could be healthy. Health and illness are co-ordinated factors, factors which are involved in community well-being. The day of a hospital being completely apart and the patients in it not being part of the community is long past and I hope that we will have a more integrated system with better in-bed and out-patient facilities.

When dealing with out-patient facilities not alone in the hospitals but also for patients at home, possibly by reason of age or a less serious type of illness, we immediately come up against the manner in which these people can be served and looked after. The important people in the maintenance of a good standard of health in these patients are the public health nurses and I wonder if we are sufficiently conscious of the great work these nurses do. They have a very involved schedule and much is expected of them. They are a vital element in any community care programme but their conditions of service possibly require some attention.

It is not sufficient to say that we will have one public health nurse for so many thousands of population. There are other factors involved such as the general terrain. My constituency is a classic example of extremes of population density in areas on the east coast and the scattered population in southwest Wicklow, so that the criterion of one public health nurse to so many thousands of population is not of itself sufficient. It must be adjusted to local terrain factors and also the factor of scattered population.

These public health nurses provide a good service but their numbers are still too few. They provide a domiciliary midwifery service and also general domiciliary nursing, especially for the aged. They also provide public health care for children from infancy to the end of the schoolgoing period and coupled with that, they are available for advice on health education in general. They act in conjunction with the general practitioner. I should like to avail of the opportunity to pay tribute to them and I hope their services will not go unrewarded.

In the course of his speech the Minister mentioned health education bureaus. I welcome the setting up of these but the Minister should consider adding one or two specialists to these bureaus. We have had reports that a certain sector of our community seem to be relatively well fed, if not the best fed according to some statistics, and I am not sure if that relates to food value or intake although I imagine it refers to intake. Being aware of the fact that deaths from heart disease are on the increase I feel sure the Minister will investigate the possibility of adding a dietician to the personnel on a health education bureau. I should also like to see a teacher included in the group. Although the people chosen by the Minister to date are well qualified it would be an advantage to add those I have mentioned.

The problem of medical cards will always be with us and I do not think we will ever have sufficiently high guidelines to meet the needs of the community. Nevertheless, we must proceed to up these guidelines and this should be done at least twice annually. The Minister for Finance, in his budget speech, mentioned that a review would possibly take place in September or October and, in conjunction with this review, the Minister for Health should review the guidelines for medical cards. I am aware of the Minister's desire to better these guidelines and I share his concern in regard to this scheme.

When considering this Estimate a matter which crossed my mind was the dispensing of prescriptions. In this regard I can recall reading an article which dealt with problems which arise when prescriptions are handed over to illiterates.

Minister for Health (Mr. Corish)

The prescriptions sometimes are not very legible.

Mr. C. Murphy

When such a person is given a prescription by a doctor in a lot of cases he or she does not go to the pharmacist to obtain the tablets. If the pharmacist knows the person involved and that person goes to the shop the pharmacist goes to the trouble of spelling out in simple terms the number of tablets to be taken per day. However, a difficulty arises where a second party presents the prescription to the pharmacist. Details as to how often the tablets are to be taken are given by the pharmacist to that person and that person in turn is expected to transmit the message to the patient. It happens in some cases that the second party is not in a position to transmit the message in detail. This problem could be got round if the doctor when he writes a prescription for such a person put a capital "I" on the top of the prescription. This would make the pharmacist aware of the position. I have spoken to a number of pharmacists about this problem and they admit it exists.

I hope the Minister will give favourable consideration to the establishment of a community hospital in the Arklow area. I would be obliged if he would inform me when we might have finance and be given the go-ahead for the health centres not only in Arklow but in Dunlavin and Blessington. I should like to pay tribute to the staff of the health board serving my constituency. I have not known the staff for long but during that period they proved helpful to myself and the people of the region.

Mr. O.J. Flanagan

I intervene in this debate because I realise the importance of the Estimate for the Department of Health. With the most imaginative thinking possible no Minister for Health could possibly realise his visions or dreams in so far as the health services are concerned. This is something which must be linked up closely with the Departments of Social Welfare and Local Government. Of the number of people who are seeking medical care and hospital beds a big percentage need this attention because of bad housing. As a first step towards a general improvement of health standards we should ensure that every family lives in an airy and properly equipped home. Until such time as all families live in healthy homes we cannot hope to see any improvement in the health of our people. It is alarming to see the number of people who have a medical problem because of their housing conditions. If the Minister is to realise his ambitions he must have close contact with the Department of Local Government. If necessary he should establish an inter-departmental committee in an effort to improve housing conditions.

We should ensure that the public are properly educated with regard to health matters. The greatest gift is good health but there are very few people who make a study of it and who take the necessary steps and precautions to retain good health. If we had a proper educational system that put a proper emphasis on health and good living it would considerably relieve the financial strain on the State with regard to the provision of hospitals and the necessary services and it would also ease the strain on the medical profession. No matter what the Department of Health may do, it will be to no avail until the people are educated on the real essentials of life. They must know what steps to take to safeguard their health.

There should be a campaign in every area to advise people on the type of food to eat and what to avoid. The major diseases in this country are cancer and heart diseases. Many people say there is no cure for cancer but early diagnosis and treatment together with care and attention will reduce the number of deaths. I do not know what is our contribution to cancer research but it could never be enough. The amount of money spent on this research throughout the world is money well spent. We should use some of the EEC funds for this purpose, although I admit they are not extraordinarily large at the moment. An international effort should be made, in conjunction with the United States and other countries who are experiencing high death rates from cancer, to pool financial resources and to examine all possible means to conquer the disease.

As a matter of urgency, this country should have hospitals that would cater exclusively for cancer patients. Outstanding work has been done by existing hospitals but their resources are not sufficient to cope with the problem. Sooner or later the Department of Health will have to provide large, well equipped hospitals to take the strain from the existing hospitals treating cancer patients. At present many patients are on waiting lists because they cannot be accommodated in our hospitals.

In the late thirties and the forties this country had a serious problem with regard to tuberculosis but, as a result of a major drive in the provision of hospital accommodation, that problem was overcome to a great extent. However, we should not make the mistake of thinking tuberculosis is a disease of the past. Statistics show that there are still quite a number of people suffering from that disease and we must not be under the impression that we have completely solved the problem.

When people are in good health it is vital that they be educated on the best way to retain it. It is astonishing to realise that many thousands of people are living on tablets and drugs of all kinds. What has happened to this country? There has been an extraordinary change in recent years. People in all walks of life seem to take tablets and drugs four and five times a day. Do they really know what they are taking? Have all these drugs been prescribed by doctors? Is it the situation that some medical people are pushing these drugs on the public in an effort to relieve pressure on their surgeries and consulting rooms? The indiscriminate use of drugs and tablets is wrong and the sooner our people realise that the better. Many of the people who are taking these tablets are walking around in a daze. It will be a problem to break them from the habit of continually taking drugs and medicines. Years ago people lived to a ripe old age without the assistance of these drugs. They knew what good, wholesome food they should eat and they knew how to guard against infection and disease.

I have never understood why health foods were subject to tax. These foods are of a very good quality. I do not know why the various brands of imported health foods were subject to tax. I would ask the Minister for Health to consult with the Minister for Finance regarding this tax in relation to health foods and ensure that so far as natural foods are concerned they will not be subject to tax.

I want to pay tribute to those who have been associated with the blood transfusion service and to all those responsible for keeping a blood bank. I also want to express appreciation of voluntary blood donors. I trust that whoever is responsible in this particular sphere is satisfied we have sufficient blood in stock at all times to meet any great emergency that might arise. One is always hoping that catastrophe and disaster will be avoided but it is absolutely essential that the blood bank should be built up to the very maximum so that, should tragedy befall us, there will be ample supplies of blood readily available. The people involved in the blood transfusion service are doing an excellent job.

Our aim should be—it is the aim of the Minister—to treat people outside of hospital rather than in hospital. Steps have been taken in that direction. Well over 1,000,000 people are now covered by medical cards and are entitled to completely free health services. I do not describe myself as a 1975 socialist—I emphasise the 1975 —but I am a believer in free health services for all of the very best kind that can be made available. Those who have no free health services are paying through the nose to subsidise those who have these services. In the case of those who have to pay for services, particularly where large families are concerned, hospital charges and the cost of specialist treatment are outrageous. I know not one, not dozens, but scores of people who deliberately avoid going to a doctor because they are afraid they will have to go into hospital and, not being covered by free health services, they fear the financial consequences. That is a shocking situation. No human being should be in the position of putting his or her health at risk because of fear of financial stringency.

I implore the Minister to ensure that all our people will be treated equally and that the best free medical services will be provided for every man, woman and child in the State. Where, the Minister may ask, will the money come from? Whatever happened to the free-for-all health services, we were told some years ago would be available to all for the price of a packet of cigarettes? If everyone were contributing it would be possible to provide all our people with proper free health services. Then no one would enjoy better treatment than another. Let there be no question whatever about it, the man who can pay will always be sure of the very best treatment. We should drop the pretence that there is no difference as between those who can pay and those who cannot. There is a vast difference. The man with the financial resources can get the best treatment available inside or outside the country. I implore the Minister and the Government, whatever difficulties may have arisen with any branch of the medical profession, to make use of the conference table to resolve the difficulties. We are always talking about negotiation and reconciliation in other spheres. Why can there not be negotiation and co-operation where problems relating to health are concerned? If the conference table is utilised and there is goodwill any difficulties that exist should be capable of being resolved satisfactorily.

Ministers change and Governments change but the personnel in Departments do not change. It is there we want a real change of heart. I remember being on numerous deputations to various Ministers for Health right from the late Dr. Ward to the present day. The deputations invariably ended up with the civil servants making suggestions and proposals instead of the deputation telling them exactly what they wanted done. Deputations do not visit Departments to find out what the official departmental view is; they go with the intention of convincing the bureaucrats of a particular course of action they want the civil servants to take. Where there are fixed ideas, many of them emanating from Victorian times, it is impossible to make progress. There must be a change of heart at both governmental and local level. I know it is hard to cure an old dog of his trot and it is hard indeed to convince highly qualified, professional civil servants; that is why I say an effort must be made to bring about changes right through. I hope an effort will be made now to embark on free for all health services. I am a believer in them. I have seen the hardship middle class people undergo, people whom we regard as well off until they fall into the hands of those charged with responsibility for curing ill-health.

I do not know if any speaker has drawn the attention of the Minister to the standard of clinics. There is an obligation on health boards to provide spacious, airy clinics and it should be the duty of the Department to see that the clinics are inspected frequently. I have seen clinics where outpatients were packed like sardines in a tin, where there was no proper seating accommodation or proper ventilation or a reasonable standard of comfort. I cannot understand why the consultants send for so many patients at the one time. Is it due to transport problems?

It would be interesting to know the amount of the sum voted for Health that is spent on the transportation of patients from clinic to clinic and from hospital to hospital. I do not intend to be critical of those who earn a livelihood in transporting patients. It should be open to health boards to give a petrol allowance to a neighbour who would be prepared to transport a patient who had not a car. There have been cases where patients have been brought around the country for miles and for hours while other patients were being picked up or set down. This is an unsatisfactory arrangement. It must be replaced.

A survey of clinics should be undertaken and they should be visited frequently to ensure that they are not overcrowded, that proper accommodation is provided, that there is a proper way of receiving patients and that the clinics are fully staffed and equipped. I would have preferred not to have seen some of the clinics that have come under my notice.

We may be critical of our hospitals but we have a great deal to be grateful for. I want to express appreciation, especially to the religious who have devoted their lives to the care of the sick. I would also like to express gratitude to the wonderful girls who take up a nursing career, which is the finest vocation that any girl can follow. It is regrettable that such a large number of Irish girls cannot be trained at home as nurses. Our training hospitals are of the highest possible standard but they have the maximum number of trainees that they can accommodate and the prospect of getting girls into them for training is practically nil. I should like to ask what practical steps have been taken in recent years to ensure a greater intake of Irish girls into Irish hospitals where there are training facilities or to establish new training hospitals so that girls will not have to emigrate to be trained in England and elsewhere. It is a serious problem from the point of view of administration that so many girls have to emigrate to train abroad. I trust that the Department will take note of this matter.

The Elm Park Hospital is one of the finest hospitals in the world. Another fine hospital is the regional hospital in Limerick. I have not been in many hospitals except to see patients but I realise what it is to be in hospital, having been a patient many years ago for a much longer period than I care to remember.

Most of our hospitals could do with a general overhaul to bring them up to modern standards but when our hospitals are compared with hospitals that we visit abroad we realise how very well off we are. I visited a hospital in Copenhagen to see a patient and a hospital in Paris, to see a patient. I was not impressed. I certainly was not impressed when I visited the Bellevue Hospital in New York to see a patient. That hospital left a lasting impression. When one visits hospitals abroad one realises that some of our major hospitals are much more advanced. In the Bellevue Hospital in New York there are wards in which there are over 100 patients of all creeds, classes and nationalities. In the clammy atmosphere of New York city this is not a very pleasant experience. Because of location, the hospitals in this country are superior to many of the hospitals I have visited abroad. I have only visited two hospitals in England and that was in the city of Manchester. Any Dublin hospital impressed me more.

Our hospital staffs are dedicated people. I should like to express appreciation of our doctors, physicians, surgeons, psychiatrists for their wonderful devotion to duty and their loyalty to their patients. These people are extremely proud of the high standards of their profession.

I do not suppose that there will be many Deputies doing it but I want to express appreciation of the doctors in this country who have taken a certain stand against abortion and who have clearly and openly expressed their opinions in no uncertain terms. I have not heard a single utterance from the Department of Health advising people of the dangers of abortion. I have not seen one practical step taken to have a proper investigation about the means by which thousands of Irish girls are being ushered out of the country to have abortions performed in Britain and elsewhere. The Department of Health are closing their eyes to this problem. Do they know what is going on and are they happy it is going on? Have they taken any steps to investigate who is responsible for sending those girls out of the country to have abortions? Who is making the arrangements? It is very easy for them to say that it is a matter for the Garda and the Department of Justice. This matter calls for explanation and also warning of the dangers in relation to these activities abroad.

I want to pay a very special tribute to the Pharmaceutical Society of Ireland and to the chemists for the stand they took in relation to the contraceptive campaign. They acted correctly and wisely. If there is no other voice in the House to express appreciation for the stand taken by the chemists of Ireland I want to do so now. I want to express thanks for the firm stand they took at the time and which they conveyed to the responsible authorities.

I want to make a very special reference, as a member of a health board since health boards were established, to a matter of vital concern to any constituency. My constituency is within the midland region, which comprises four counties. I know the Minister for Health, like most Ministers from time to time, has to make some very difficult decisions but he will be faced very shortly with a decision, when considering the hospitalisation of the midland region, on the provision of a general hospital for that region. I have made a number of submissions on various problems from time to time to the Government and I am glad to say that many of them have been acted on.

I made a submission to the Minister for Health on 9th March, 1974 based on my dealings with the public, my knowledge of the midlands and my practical experiences as a public representative for over 30 years. I was not concerned with the political aspect of it because if I was I probably would have given greater choice to my own county. I wanted to make a submission which I felt was in the interests of health, the interests of the midlands and the provision of proper health services. I refer to page 125 of the Fitzgerald Report, a much talked about document. I do not know what has happened to that report, whether it is still active reading for the Department of Health or whether it is lying on the shelves of the Custom House covered with dust and cobwebs.

This report dealt with the problem of the midlands. I do not know if the officers of the Department of Health have goggles on when it comes to reading page 125 of the Fitzgerald Report. It states:

In the Central Midlands areas there are at present county hospitals in Portlaoise, Tullamore and Mullingar. All these hospitals are modern buildings, they are comparable in size and the towns in which they are located are also comparable in size. The three towns are situated on a line running roughly South to North: Tullamore is 20 miles north of Portlaoise while Mullingar is 22 miles north of Tullamore. In our consideration of this area it was clear to us that the development of General Hospitals in more than one of these centres would be difficult to justify.

I understand there is a sub-committee of the Cabinet already dealing with this matter. Have the Department submitted to each member of the Cabinet on this sub-committee my submission of 9th March, 1974 so that I cannot be told later on they did not know anything about it? I want that on the record of this House. If the Department of Health have that submission I am sure it can be conveyed to the Ministers in the Cabinet sub-committee dealing with this and other problems.

I want the House and the Minister for Health to understand clearly the problem in relation to hospitalisation in the midlands. Whatever is done now is unlikely to be undone and whatever decisions are taken now will have an effect on the livelihood and the health of the people of the midlands for over 100 years from now. The Fitzgerald Report further states on that page:

In considering the merits of the different centres we had regard to the impact of our selection on the areas to the north and to the south. If, for example, Portlaoise was to be developed as a General Hospital centre it would infringe on the area which one would expect might be served by Waterford General Hospital while Mullingar, if chosen for development, might be expected to draw patients from Cavan without adequately catering for the Cavan/ Monaghan area.

I want to draw the attention of the House to this part of the report in particular. I presume it has already been done by other Deputies for the constituency. I want to go on record as strongly recommending the submission in the Fitzgerald Report on this matter. Tullamore is roughly half way between Mullingar and Portlaoise. It is reasonably close to both and it is centrally located. The entire area is now served by three hospitals. We feel that Tullamore has a strong claim for a regional hospital.

The alternative to that is to have hospitals in Portlaoise and Mullingar. We are of opinion that the development of major hospitals in both those towns, which are relatively close to each other and which are within easy reach of Dublin, would not be justified. Accordingly, we recommend the selection of Tullamore as the centre for a regional hospital. Tullamore has been recommended in the Fitzgerald Report. I am not an Offaly man. I am a Laois man. Has the Fitzgerald Report gone down the spout or up the spout? Is it covered with dust and cobwebs and placed in safe keeping in the vaults of the Custom House?

Anybody who wants to cater properly for hospitalisation in the midlands region knows that there must be a hospital in Portlaoise and a hospital in Mullingar but, for major hospital treatment and attention, both of these hospitals can feed a regional hospital in Tullamore. The Mullingar hospital and the Portlaoise hospital send patients to every hospital in Dublin. There is enough pressure on the Dublin hospitals from the tremendously growing population in the city. Nobody suggested, and the Fitzgerald Report did not suggest, that the hospitals in Mullingar and Portlaoise should be closed down or downgraded. If they were expanded and extended they could function effectively and efficiently and, at the same time, they could feed the central hospital in Tullamore with patients who otherwise would have to be sent to Dublin.

I am not happy with the attitude of the Minister's advisers on this matter. I am not happy with the attitude of Custom House bureaucrats telling us where the Minister should decide our sick people should be treated. We are public representatives with knowledge and experience. We have the capacity to know and understand this matter. We are members of health boards. Our advice and guidance should be of more importance than those of a civil servant who, apart from an occasional holiday, was probably never more than a quarter of a mile from the Custom House. We know what we want.

In a general hospital various units are required for general surgery, general medicine, ear, nose and throat treatment, casualty services, out-patient services, radiology, pathology, nursing training schools, and so on. Are these to be attached to what are described as the mini-scale hospitals in Portlaoise and Mullingar? Is the midlands region to be the poor relation? All the other regions will have their central regional hospitals but we are to have two mini-scale hospitals.

A mini-scale hospital has not been defined but the fact that the word "mini" is used means that something will be lacking. The Minister's advisers are being penny wise and pound foolish. I want to go on record as uttering a warning against the provision of mini-scale hospitals in an area where experts have recommended that a general hospital should be provided to cater for the entire area but not at the expense of closing down the hospitals either in Mullingar or Portlaoise.

What will happen in Offaly if the supposed mini-scale hospitals are approved by the Department? Tullamore and the surrounding area has a population of 22,000 people. It should be selected without question for a general hospital. This country has not benefited from blessings from the present Government or from previous Governments. Is it to be denied the solemn right which professional gentlemen recommended to the Department after an examination and a survey were carried out? If these mini-scale hospitals are provided, possibly they will not be fully staffed and they will not be able to give the services which will be sought. The people of Offaly resent this.

I strongly and sincerely recommend that the idea of mini-scale hospitals for the midlands should be dropped. If a job has to be done we should not consider halfpennies and pennies. We should do the job properly or not do it at all.

The establishment of such mini-scale hospitals will rob for all time the region of its own central and general hospital. Or is it intended to depart from the regions altogether, to abolish the idea of regionalisation? My understanding was that each region was to be an independent unit, with full health facilities of every kind, ensuring that the region was adequately catered for so far as hospitalisation was concerned. There will not be a round the clock service in such mini-scale hospitals because the staff will not be available. The highly skilled medical men will go to the general hospitals in preference. As a result, we in the Midlands will be the victims of an ill-conceived and speedily taken decision. I beg of the Minister to remain calm and not allow himself to be rushed into anything in this regard. The future must be considered when perhaps none of us will be here. Let us not do anything which would be a hindrance to hospitalisation in the Midlands. That is why I plead with the Minister to adhere to the decision of providing a general hospital for Tullamore. Mini-scale hospitals, in my opinion, are nothing more than a doubling-up of the consultancy staffs of the present county hospitals. I want to know are people of some areas to lose their county hospitals so that this doubling up can be implemented, or can they be guaranteed any better service than they receive at present by so doing?

At present 40 per cent of patients residing in the Midlands are treated outside the Midlands area. This must and will continue if the suggestion of the mini-scale hospitals is implemented. There is an onus, not alone on the health boards but on the Department of Health, to provide the necessary services and cater for the 40 per cent at present being catered for outside the Midlands area. I make this plea for the sake of raising the standard of medicine in the Midlands but, more particularly, for the health and welfare of patients. Cannot it be argued in sane and financially wise terms that the best, surest and safest line of action is the provision of a central hospital for Tullamore, which I strongly recommend?

An Leas-Cheann Comhairle

I intervene to inform the Deputy that he has five minutes left.

Mr. O.J. Flanagan

In those few minutes I want to refer to Irish doctors who qualify here at great expense to their parents and others and then emigrate, which is a tremendous loss. Practically every hospital in Britain and now many in Canada and the United States are being fully staffed by Irish doctors. We export too many doctors and a survey taken has shown that more than 60 per cent of our doctors graduating over a five-year period emigrate. That is a startling disclosure and one which must alarm us when we see shortages of doctors in so many parts of this country. I cannot understand it. Perhaps, when they qualify, they have a desire to go abroad. But I feel that is not so. There is employment available for them here and for that reason they should be encouraged to remain at home.

I want to make brief reference to the provision of adequate accommodation for mentally handicapped children. There are quite a large number of mentally handicapped children being cared for at home who, despite allowances granted, would be much better off in suitable institutions. But I deplore the fact that such mentally retarded children have to be sent to existing psychiatric hospitals. We should make resources available for training the necessary staff, and I understand that it is the staffing of such institutions which constitutes the main problem.

I want to express appreciation to the Department of Health for all they have done for disabled persons. Since 1st April, 1974, no person, irrespective of his income, need pay more than £4 per month in respect of drugs and medicines, which was a welcome provision. But, in view of the increases that have taken place in the price of drugs and medicines in recent times, this matter might be examined further. I shall not make reference to medical cards because I am a believer in free medical services. I am not at all happy about the cost of the establishment of health boards at present. I do not know what the ultimate result will be but I am a member of a health board and I am satisfied beyond all doubt that the extent of the improvement in our health services has not compensated for the extraordinary amount being expended. There are too many officers and officials, too many file-keepers; there seems to be developing an overgrowing local bureaucracy in every area which must be scrutinised by the Minister. It may be a difficult job to undertake but, once engaged in, would yield results. I hope an effort will be made to improve general standards in future years.

Mr. Brennan

The Minister's opening speech to the House on this important Estimate, like many others, reflects the rate of inflation which has bedevilled every Department and is the cause of a lot of the trouble being experienced at present in relation to the social services and the whole economy. However, this debate is not one on which we shall harp again on the lack of attention being given to inflation, which is now accepted as having been caused in the main domestically. The Minister's reference to the phenomenon of inflation bedevelling every health service in the world is not a sufficient excuse for the lack of effort being made to bring about some improvement in the rapidly ascending graph at present frightening our people. The Minister's opening speech simply points out the additional expenditure being provided in the current year. It continues to say that that will make for a little improvement in addition to the maintenance of existing services. In other words, £29 million extra on current account will merely keep the show on the road. And that makes allowance for all the optimism written into what is, in the main, a speech which sought to bring in the bits of cosmetics that might dress up something in the absence of real, solid progress.

The Minister's statement about this very important Department was not very encouraging. At the base of all our efforts in Government must be the health of our people. In the absence of any real progress the Minister mentioned many unimportant items but did not neglect to have a swipe at the out-going Administration. This did not fit in with what should have been an important statement dealing with one of our most important Departments. When he introduces that political note he builds up expectations of what is going to happen and then points out that such an achievement could not have been matched by the out-going Government. I do not know what that has to do with the health service.

He outlined his hopeful plans for the future. He also referred to the White Paper on Mental Health and Employment for the Handicapped which will be published at some time in the future. He said that this would be an achievement of which all could be proud. He also took credit for an "overall hospital plan". At column 53, Volume 281, of the Official Report he said:

We will have taken the first step towards the creation of a fully modern, acute hospital system and solved a problem whose solution has evaded previous administrations.

He is taking credit in advance for anything that will be done in the future.

In the past there has been a proliferation in the Department of Health of committees, advisory bodies, councils and reports and before one report is properly studied, it is being superseded by another. In his speech the Minister promised another report. That is one thing we are not short of.

The Fitzgerald Report basically sets out a scheme for hospitalisation based on specialised services, bringing specialised services to the regions, proposed closures of hospitals—all of which met with opposition—extension of others and the building of new hospitals. Comhairle na nOspideal made other suggestions and plans. They acted in great haste with regard to some of the changes for which the physical structure was not yet available. On the whole, the regionalisation of the hospital system created a new basis on which any Minister could find ample scope and opportunity for vast improvement. This system is in its infancy and still requires a tremendous amount of development, particularly from the administration point of view, to put it into shape as a properly geared and working system.

What Deputy O.J. Flanagan said was true. The cost of the health services is mounting at such a rate that one can hardly visualise where it is likely to end. The uncontrolled and galloping inflation which we are experiencing at present can have a serious effect on people trying to live on a modest income and where the adjustment of such income has not kept pace with inflation. These people may find themselves faced with very high health bills. Health expenses are no longer paid by patients alone but by everybody who contributes through the taxes being foisted on them day after day.

As I said, there are many committees, consultancy bodies and ad hoc councils making reports and carrying out examinations. They would be better employed if they turned their attention to ways and means of getting the best health service at the lowest cost. These matters must be tackled by any Minister or administration who wish to solve these very serious problems.

I am not satisfied that the health service is commensurate with the amount of money being spent on it. I am not satisfied either that the regionalisation programme has, from the administration point of view, been as successful as it should have been or as, in theory, it was expected to be. I am prepared to accept that the development at the infancy stage may not be properly guided. We should now be trying to get these regions working on a more satisfactory basis. A good many years have elapsed since they were first set up but we are not getting the improvements we were led to expect at the time.

In the western seaboard counties a great many patients had to go to Dublin for specialist treatment. The journeys were costly, putting visiting beyond the reach of relatives. We thought then that by now we would have got rid of that by having larger hospitals providing specialist services within the regions, but we know that a great many patients still have to be transported to Dublin to get these services. One must ask what efforts are being made to ensure that these specialist services will be made available within the regions.

I agree with other speakers who said that adult health education forms the basis of any progressive health system. If we are to examine the costs and to get the best possible return from the lowest possible budget, we must concentrate on adult health education. We agree that the improvement in medicine generally has given us a new longevity average, that life expectation has been extended. The last speaker decried the use of drugs and said that people lived longer in earlier days without drugs. Everybody knows that is not so, that life expectation has been lengthened and child mortality reduced to a minimum. Geriatric services have been improved and extended and this is showing its effect.

As I have said, adult health education would not only improve general health in the community but it would lower the cost of the services. The schools could be used during their many vacant periods for the teaching of the rudiments of better health. I do not see how medical practitioners could be better engaged than in holding weekly or monthly clinics and lectures on adult health matters. In this way a whole new era of preventive medicine could be established which would reduce costs and improve health. The number of people eating and drinking themselves to death is very great and much of it could be eliminated if local GPs were to hold periodical clinics in local schools.

The school medical service initiated many years ago has not been properly developed and this is the greatest sign of neglect in the health services generally. No Minister for Health can boast of having made progress in the extension and improvement of the medical services who has not fully developed a proper schools medical service. All of us could see the benefits of such a service where it was operated properly. We have seen children with congenital troubles in poor families whose complaints would never have been attended to because of lack of medical examination if it were not for the school medical service. It made it possible to have the complaints recognised and to have treatment prescribed which meant that these children were able to take their place in the world as normal human beings.

While on this subject of the decline in the school medical service, it is necessary to say that the dental part of the school service is a laugh. We are now in the days of preventive dental treatment and it is most essential that children should have their teeth attended to at an early age. There are areas where the service has not been carried out for years and others in which it has not been followed up with required treatment. We cannot say we have made progress in the medical service if we have not developed the most critical and essential part of the whole scheme, the school medical end of it. A proper school medical service would mean a tremendous reduction in medical costs for many people in future years.

Immunisation schemes are reasonably well attended to but are not publicised to the necessary extent. Sometimes all that is given is a mere announcement in the church on Sunday that vaccinations or innoculations will take place in particular schools during the week. I suggest that teachers might, with the aid of pamphlets, explain to children how imperative it is that they should avail of these schemes. I ask the Minister to concentrate on this and I impress on him again the need to develop a good school medical service.

I have already dealt with adult medical education and have pointed out how essential it is that people should be instructed on what their habits should be and what they should avoid. These days one reads that something causes high blood cholesterol and that something else will be contributory to malignancy.

Firms producing different foods and medicines are frequently disturbed by the misguided, unqualified statements made by any particular body when in most cases what is actually meant is that these things should be used in moderation. Immense damage is sometimes done to the production of good foods by people being told they should avoid them, whereas it is their over-use that is to be avoided. It is the Department of Health who should make official pronouncements on these matters and not leave it to the Readers' Digest or some other publications to make fantastic announcements time and again based on nothing but a small statement taken out of the context of a lecture given by some professor who stews up all sorts of exotic ideas——

Mr. Corish

Probably with an honorary degree.

Mr. Brennan

——in order to produce a thesis or address some international medical body. Adult health education in itself could eradicate from people's minds some of the misunderstandings and false beliefs they have in regard to certain commodities. There is a fortune to be made out of producing books on slimming, and I suppose that will go on to the end of time. Here, again, immense damage can be done by people who are not qualified to give advice. It is a matter for the local GP or the medical practitioner who is qualified in that field to give the proper advice.

There are other things which are habit-forming and detrimental to health which may be outside the scope of medicine to some extent, for instance, alcohol and drugs but, nevertheless, are very much a part of the medical field. I do not know if there is proper co-ordination between the different bodies who deal with these problems. The greatest organisation this country has ever had is Alcoholics Anonymous, and I am not too sure if they get the full support they deserve from the medical profession. The Minister should let us know if there is appreciation by the medical authorities of the immeasureable value of the work these people are doing, dedicated people, which is the basis of the whole success of that organisation.

On the question of dedication, I wish to refer to the voluntary services in regard to health. If we are to get the best possible services at the most reasonable cost to the country, we shall have to continue to expand the community service given by the voluntary bodies that have grown up and that are doing such a tremendous job. During our period in office we saw fit to introduce, for the first time the idea of subsidising people who heretofore were engaged mainly in raising funds by various means, voluntary subscriptions, giving them statutory significance and assisting them to carry out the important work which only they can do particularly in the field of geriatrics and many other fields as well.

As Minister for Social Welfare, I have experience of the important work carried out by voluntary bodies generally. They perform a service which no Department could do by any payment of benefits by way of pension or otherwise. For lonely old people an organisation of this type is indispensable to every district. It should be set up on at least a parish basis with proper co-ordination. There is a council now and the Minister announced that he has added a few names to it to co-ordinate their efforts and to guide them generally in the immense variety of work they can undertake in the field of medicine as well as that of social service. That is the direction in which we should move if we are to minimise the cost of the health services which are alarming at present.

Apart from the proper organisation of the administrative staffs of the different regional health boards, there are many other ways in which the cost of medicine could be minimised. I, too, like the other members of the party to which I belong, believe those who can afford it, should pay in order that the service may be properly developed for those who need the service and cannot afford it. The insurance side is one direction in which much organisation is required at present. I am not sure that some people are quite clear as to whether the voluntary health insurance is a benefit at present. With the abolition of the insurable limit, many people found themselves qualifying for health services for which they were already insured under the voluntary health scheme. There is over-lapping there, and I would like the Minister to inform us to what extent this over-lapping has been examined, and to what extent it occurs. Is it a fact, as I believe happens, that, in certain cases where people go to hospital, they can gain on their hospital bill, which may be attended to in two ways, through the social insurance scheme as well as through the voluntary health scheme. At a time when the health services are costing so much, such overlapping is very serious.

The voluntary health service is very important; for those who have no other service, it is essential. In the case of people who have become entitled to services on the social insurance side which they already had through voluntary insurance there is need for a good deal of examination to ensure that there is not unnecessary expenditure in an area that is already too expensive. That does not say that we should not fully examine the possibility of having as much of the service as possible covered by voluntary insurance so that people pay where they are in a position to do so and that we develop the community service to the maximum because dedication, voluntary effort and local contacts and knowledge are the most valuable things we can have. This would considerably reduce the cost of the health service and it is something to which the Minister should give priority.

The Minister recited a litany of proposed extensions to hospitals most of them dating back many years and much of the planning already obsolete before the work has begun. I wonder if plans regarding hospitals and structures associated with the health service are sufficiently researched in the long-term. One frequently sees that less than a year after a new hospital has been built there is a demand for an extension and by the time it is extended other facilities, such as theatre or kitchen facilities are not in keeping with the extended hospital. Hospital planning should not merely provide for what is currently regarded as necessary based on bed turnover in existing antiquated hospitals but should take account of the rapidly changing outlook in medicine generally, the rising population, the higher marriage rate and lower average marriage age as well as the extension of the upper limit on the geriatric side. Are all these things considered when planning, particularly movement of population in an area?

I want to refer to what is happening in the north-west region, the one I know best. When the Minister lists the building projects of the different health boards one finds it includes proposed extensions and buildings some of which have been on the drawing board for five or ten years. We in public life who must frequently visit hospitals in our own area, always find there are unfilled expectations in respect of every building—proposed extensions, plans for improvement or rebuilding programmes long ago approved. The increase in the Vote, which on the Minister's own admission will do little more than keep the show on the road, is not very encouraging as regards expansion of health services in the immediate future.

Chemists have recently been perturbed about their place in the health service. I have no illusions about the problem involved but I hope the Minister will be able to approach all the sections contributing so much to the health service in an understanding way. At present a chemist would require an extra clerk to do the documentary work involved in the health scheme regarding the dispensing of drugs and provision of pharmaceutical services generally. They complain that the time-lag in getting payment for drugs dispensed is unduly long. When money costs so much everybody wants prompt payment and while bodies may be sure, they are not always prompt and much money can be lost on interest rates as a result of extended credit. Public bodies should give the best example in this regard and make payments promptly. Chemists sometimes have to wait for periods which nobody in ordinary business life would tolerate.

The chemist is playing a very important role in medicine at present and should not have to resort to selling costume jewellery and other items outside the pharmaceutical line. The service he renders and his qualification to render it should carry the greatest weight and he should be involved as much as possible in the field of medicine, which is his proper milieu. Also, he is the source from which drugs and medicines should come rather than dispensaries and clinics.

I should like to endorse what others have said in regard to training of nurses. Most hospitals seem to be understaffed and there is a tremendous demand for training. Leaving certificate girls find it difficult to get into training hospitals. There is need for the creation of a greater number of places for trainees. The profession is one that requires dedicated people. I often marvel at the number of girls who are anxious to enter the nursing profession but there are many others who would embark on a nursing career too if the opportunities were available. Many girls go to England to receive their training where it is easier for them to be placed than if they remained at home and, also, where the cost of training is much less than here. Indeed, in most cases they are not required to pay any fee for their training. Unfortunately, though, these people do not always find it easy to find places in hospitals here if they wish to return, although many hospitals are not staffed fully.

Nurses have told me from time to time that, in order to overcome the difficulty of staff shortages, they must forego their days off. That position should not prevail. The conditions for nurses should be made as attractive as possible. During the past few years tremendous advances have taken place in working conditions generally but there is much to be desired in so far as many hospitals are concerned. I remember a time when psychiatric nurses found it difficult to get a half day off in the week. They worked very long hours but the situation has improved considerably although that is not to say everything is perfect.

In his speech the Minister referred to his aspirations in regard to psychiatric treatment generally. He mentioned the provision of units for psychiatric treatment at some general hospitals. I wonder if this is a wise course. Would it not be better to concentrate on improving the service in the existing mental hospitals? Are we to create a situation where, supposedly, there would be a better type of treatment to be had at one place as distinct from another? It would be wrong to provide a type of treatment at clinics that would result in the downgrading of that which is carried on in the existing institutions.

In the field of psychiatric medicine, perhaps more than any other, there is much room for improvement. Although big changes and improvements have been effected in the system, there is much to be done yet if we are to bring these institutions to acceptable standards and if they are to be as good as the hospitals or institutions where other diseases are treated. The old image of the mental hospital with the huge community room, the padded cell, the enamelled ware, the flagged floors and the untrained male staff who were selected for their muscle rather than for their knowledge is best forgotten. In those days the treatment carried out was practically nil. The emphasis was on confinement.

Any Minister for Health wishing to leave his mark on the health services has a fertile area in the field of psychiatric treatment. It is an area that should have a high place on any priority list. I do not know whether the Hospitals' Trust contribute anything to the improvement of the psychiatric institutions but if they do not, perhaps they would agree to devoting the profits of certain sweepstakes to this purpose. This would be one way of putting a crash programme into operation. I was a member of the board of a mental hospital for 14 years and during that time there were carried out what we considered to be vast improvements but, looking back, they were small enough. Much change has occurred in public attitudes to all these matters and we must do everything possible to bring about the desired improvements. Every effort must be made to find sufficient money to enable us to take psychiatric medicine out of the context of the general health programme and to give it priority rating so that the necessary improvements can be carried out both in relation to the type of institution and service and to the type of equipment available.

There have been a number of reports, among them the Fitzgerald Report, in relation to the improvement of the hospital service based on the provision of specialised services within reach of people in most areas. It is not possible to have a hospital at every crossroads. Whenever there are protests about the closure of a hospital we are treated to statistics as to the length of time it takes to remove a person by ambulance from point A to point B and we are told of the risks of patients dying on the way. This is something we cannot completely avoid in any programme but there is reason, there is an optimum, and this should not be disregarded.

It is for that reason that in relation to the members of Comhairle na nOspidéal who are overconcerned with the technicalities on the professional side rather than the administrative and human side, I think public demand should play a more important part than it has been playing. I saw the importance of the changes that took place in my county of Donegal where hospitals were proposed to be closed and catchment areas arranged for hospitals giving a bigger and better service, but the speed with which the closures took place was undesirable. I think that hospitals should have been phased out because many of them continue to give a good service.

I do not want to burden the Minister with the now well-known problem of the Sheil Hospital in Bally-shannon, but it was a crying shame that, merely in order to conform to the whims of the specialist people in the field of medicine, the human side was overlooked and the wishes of the people completely ignored and disregarded. This is a hospital on which vast sums of money were expended in bringing it up to date—a good operating theatre and all the necessary services for surgical treatment—but which could be closed overnight and hospitals to serve the same catchment area found themselves not capable of handling the number of cases being sent there.

This is something that requires the attention of laymen. Their views should be heard and the service that was satisfactory should continue until such time as the larger specialised units would have proved themselves capable of dealing with the hospital requirements of the area. That has not yet been reached. In that hospital surgery was discontinued long before full preparation had been made to accept the amount of surgery going there in any other hospital. It has been a tremendous set-back to the area. Apart from all the other points that are put forward time and again, there are the matters of proximity of relatives and shorter journeys for patients. These are all of very great importance.

We accepted the discontinuance of surgery in Donegal District Hospital on the undertaking that we would get the new hospital to give a good medical service. That is now in course of erection, but it is only a 30-bed hospital. I sincerely hope provision is made for its enlargement which will be demanded before it is officially opened. It is evident that the number of beds is inadequate. I was prepared to accept that we would get the hospital going, get it built, rather than to be arguing for years as to whether it should be a 30-, 50- or 60-bed hospital. The Minister will have to accept that there will be demands for an extension of this hospital before it is very long in existence. That was the hope at the outset, that the planning would be such that it would make for the easy extension should it be required. There is no doubt that it will be required.

The Sheil Hospital is capable of giving a surgical service for a long time into the foreseeable future and will be necessary to take the load off the Sligo Hospital for some time to come, and provision could easily be made on the basis of either visiting surgeons or a permanent appointment to ensure that this takes place. Many people have been treated successfully there in the past. Many notable personalities have undergone very successful surgery in this hospital and that it should be left entirely to medical treatment is absurb. The Minister will be satisfied that in the view of a very large section of the community surgery should be permitted to continue there until it could be phased out at a time when the people felt satisfied that there was adequate alternative provision for the many cases which passed through the Sheil Hospital. My main reason for intervening in the debate was to get the opportunity of saying that.

We all know the importance of the larger hospital unit where you have specialised treatment in the different fields of medicine but we also know that there is something attaching to the smaller hospital. There is a homeliness, a friendship, an atmosphere that is completely absent in the large unit. Deputy O.J. Flanagan talked about hospitals in some of the larger cities of the world. I, too, had occasionally opportunity to look into some hospitals in New York. This is to be expected in a large city. They are quite impersonal and the patient is merely a number.

While large units may be acceptable and desirable, there is a limit to the size they should be, and when a hospital becomes a kind of campus and patients have to be indexed to the extent that they are mere numbers, it loses a good deal of the humane side of treatment. This we had without doubt in the small units, and while there were other things lacking perhaps, they did give a good service in relation to straightforward surgery where there were no serious complications. They could still continue to do an excellent job and would take the weight off other hospitals where the bed turnover has to be so rapid that sometimes a patient has hardly had surgery until he is on his feet and moved to some other place in order to make beds available.

Acting Chairman (Mr. Healy)

I have to tell the Deputy that the time is up.

Mr. Brennan

I was disappointed that the Minister in his speech merely pointed out that the extra money provided was sufficient to maintain the service with a few improvements. The field of medicine is rapidly developing from a base which permits tremendous improvement as time goes on. The amount provided to cope with inflation is not a good enough contribution to what should be an expanding service on the capital and current side. The Minister devoted most of his speech to what he proposed to do in the future. We can all foresee thousands of necessary schemes but the Minister should have dealt more fully with improvement in existing ones. The expectations generated at the time of the regionalisation of the health service have not been realised and the improvements in the health service which should have come about as a result of regionalisation have yet to be experienced.

A lot of work has still to be done in order to consolidate the services set up and to improve the administrative side. It will have to be got across to the public that they are getting full value for the huge amount of money the services are costing.

Mrs. Desmond

I compliment the Minister on his comprehensive and encouraging speech. He has provided ample information and statistical evidence of the tremendous amount of work that has gone on in the health services. There is general appreciation of the change that has taken place in the health services and of the burden of work placed on the Minister and those concerned with health. Health is a vital area and in this context the Minister for Health has a greater responsibility than many of his Cabinet colleagues. Public representatives have also a responsibility in this area. However, I feel less capable of discharging that responsibility efficiently and fully since I ceased to be a member of a health authority. That is not a criticism of the substitution of health boards for health authorities but it appears that while health boards carry a valuable element of worker participation and industrial democracy there is little scope for public representatives who are not members of the boards to express their views. They have difficulty in representing fully the needs of their constituents.

There appears to be an over emphasis on administration. While administration is important it tends to become top heavy and in a service which was designed primarily for the well-being and health of the people most of the money goes towards administration. In my constituency the need for a forum on which to voice health problems is greater than any other area. There is no advisory health committee in that area. The Minister is aware of the circumstances involved. Cork county has been divided into three health areas—north, south and west. Those in the northern and western areas were given a voice in health matters by being appointed to the local health committees. A problem arose for the Minister and the Department when the extension of these facilities was requested in respect of the south Cork health area where there is a greater membership. But the principle that a voice would be given to the people on health matters in their own area should have been continued.

If the people in the other parts of Cork can voice their views at meetings of the health committees it is legitimate that the people of west Cork should aspire to this. I appeal to the Minister to give to the people of this area, county councillors and other representatives of the community, a forum to express their views on health. He can do this by establishing a health committee in that area. The Minister said it was necessary for him to maintain a balance between the development of the community services on one hand and the building up of hospital services on the other. The hospital element of the health service is very costly and labour intensive. It demands a high proportion of the moneys made available to the Department. There is a necessity for a rationalisation of that service and the location of major hospitals in future must be thoroughly investigated. I know the Minister is concerned to ensure that the right thing is done for hospitalisation.

Every Member has a special interest in the field of hospitalisation. From my constituency the Minister met a deputation regarding Mallow hospital and I am convinced that there is an unanswerable case for the implementation of the suggestions put forward by those people. I hope a decision in regard to this hospital will be made in the course of the next few weeks.

The element of entry to hospitals that comes to the notice of public representatives most frequently concerns geriatrics and here the balance between community care and the hospital service is most keenly felt. With the present development of community care services there is a tendency to retain old people in their own homes where possible and this is laudable. There is also a tendency to discharge old people from hospitals at an earlier stage than heretofore. This has caused unrest because the community care services are not sufficiently developed to cater for the old people who are discharged from hospital and also to cope with the demand for hospital beds for geriatrics. This is particularly the case where old people are living alone and there is much public concern for the health and welfare of these people. There is a great need for a fully developed community care service, particularly in rural Ireland.

Many old people are living with their families and here the situation is not quite so bad. If old people cannot get any benefit from hospitalisation it is obvious that the proper place for them is their own homes. However this imposes a financial strain on relatives which could be eased if the necessary financial assistance were given. The home help scheme is of great help to the old and disabled. The allowance given to a prescribed relative is of considerable help to a son or daughter who is obliged to give up employment to care for an elderly person.

The most common situation is where a married daughter or a daughter-in-law cares for an old person but there no compensation is given. In the eyes of the law the married person is not giving up employment to look after the old person and when financial assistance is sought under the heading of home assistance the people concerned are told the family income would not warrant it. In the eyes of the people who administer the social welfare schemes the married woman is held to be maintained by her husband and therefore does not qualify. This discriminates against married women who are giving a service to the elderly and who deserve remuneration for it. Because they are mainly the group who give that service, financial assistance would be of considerable benefit to them. By caring for old people in their own homes the strain on hospitals is greatly eased.

The Minister referred to the role of the community care services especially with regard to geriatrics and he stressed the need for such services. However it will require a very comprehensive service, not just for the elderly but for those in need of medical help. In addition, an extension of the service provided by social workers will be required. It has always occurred to me that as a professional group the scale of pay of social workers does not compare favourably with that enjoyed by other professionals. I suspect the reason is that they are mainly female workers. Having regard to the increased emphasis on social work and the pressure of such work, their scale of pay should be brought more into line with that of other professional groups.

It is frequently brought to the notice of public representatives that the accommodation in orthopaedic hospitals is inadequate. There is a constant waiting list for beds in the Cork Orthopaedic Hospital and the only hope a person has of getting early treatment is to pay for a bed and the services. That is a dreadful indictment of the present system and it is the best case that could be made for the Minister to bring about an end to the present system and give free hospital care for all.

In a short time we will look back in disbelief and horror at the present system where, regardless of the extent or the degree of urgency of the illness, what decides a patient's admission is the ability to pay. I was surprised to hear some Deputies dismiss the Minister's laudable attempt to end that kind of system. Some of them called it a pipe-dream but that is not the cause because to settle for less would not be worthy of any Minister for Health. I hope the efforts being made by the Minister to provide free hospital services for all will be successful in the near future. He has encountered many problems and difficulties but it is my hope that he will be successful in what he is setting out to do.

There is a constant demand by the public for extension of the medical card system and for an increase in the income limit. I would definitely say without hesitation that to assume a husband and wife with £24.50 a week are capable of meeting incidental medical needs, such as family doctor and so on, is certainly not a fair assumption. Indeed, any such assumption is bound to impose grave hardship on those concerned.

We should appreciate that, no matter how well-intentioned the Minister is—and I know the Minister is well intentioned—there is a considerable financial problem involved. He has told us that a £1 increase in real terms in the income guidelines for medical cards would cost £1 million. That is a very sizeable sum. The question is: are we prepared to pay the price? There is the additional problem that a particular organisation has already stated it will seek a review of fees if medical card holders go beyond 40 per cent. We should not overlook this when pressing the Minister to extend medical card coverage. In fairness to the Minister, it must be said that, since he came into office, there has been a considerable extension. In December, 1972, shortly before the Minister took office, the number holding medical cards was 28.4 per cent; at the end of March, 1975, three years later, the number was 35.2 per cent. While the Minister may have had no direct decision in the matter I am convinced it was certainly due to his influence that the number of medical card holders was extended. While we are all of us working towards completely free hospital care and a comprehensive free medical card scheme we must appreciate the steps taken in the interim to extend medical cards.

There is a belief in the minds of some people now that medical cards are harder to get. I believe the figures I have given demonstrate that there is no ground whatsoever for this belief. However it does appear to me that less discretion is being used in hardship cases. This may possibly be as a result of the introduction of recoupment of the cost of drugs. I believe a good deal of discretion should be used in cases just outside the limit. There are many people with long-term illnesses who do not qualify for special consideration, such as people suffering from asthma, rheumatoid arthritis and nervous disorders generally. Housewives suffer from nervous disorders and they need medication. There ought to be more discretion. Perhaps the scheme could be extended to cover sufferers from these long-term illnesses. Those on incomes just outside the eligibility limit for medical cards do not always have at hand the money to buy the drugs required —the recoupment of drug scheme is an excellent one and all credit to those who brought it in—and they are not in a position to wait for recoupment. Hardship is caused in many cases. Recoupment does not provide a total substitute for some kind of card, be it a personal card or a hardship card, and we should operate the scheme to a wider extent than it is being operated at the moment.

We have all given an unqualified welcome to the choice of doctor scheme. It works well in built-up areas. There are however problems in rural areas remote from towns and the larger centres of population. Doctors will not live in these remote areas. We have problems in my constituency. Recently a representative group in Ballyvourney, halfway between Macroom and Killarney, brought to our attention the fact that there is no doctor resident anywhere between Macroom and Killarney. This is an area into which there is a tremendous influx of people during the summer months and the local people are aware of needs that could arise which will not be met unless some incentive is given to a doctor to reside in this area. A better service to meet particular needs in local areas will have to be provided and that service will have to be on a par with the service provided in built-up areas.

The Minister referred to dental and ophthalmic benefit schemes. He expressed some dissatisfaction. We share his dissatisfaction. Those with medical cards or limited eligibility do not receive the same treatment as do those who can pay. The services provided cannot meet the demand—this is another problem—and there is a tremendous build up of people needing dental and ophthalmic treatment. Some solution will have to be found to this problem. Where the school dental service is concerned, this should be extended into post-primary education. Many children do not suffer any dental problems in the primary school; it is when they go into post-primary education that the need for dental care really arises. Sometimes defects do not show up in the primary school. There is no dental treatment for children in the secondary or post-primary school. There is urgent need to extend dental services into both secondary and post-primary schools. It is very vital in the teenage period.

In the area of dental and ophthalmic services there is the old story of the insured person being covered for only partial benefit. The provision of spectacles and dentures and payment for treatment, particularly in the case of the wives of workers of limited wages, imposes a great strain on these families. If the health service is to be comprehensive it should cover all of these matters.

The disabled person's maintenance scheme is a very good scheme. I may have done so before but I would again compliment the Minister on invoking the regulation which made the scheme available to all disabled persons regardless of family income. Before the Minister came into office the position was that the disabled person's maintenance allowance was based on a means test and if the disabled person lived with his family or if a brother or a sister in a family was deemed to be earning and capable of supporting him, the disabled person did not qualify for the allowance. The allowance now, £8.60 for a single person and £15.75 for a married couple, is a step in the right direction. The allowance is rather small but it can be supplemented, perhaps, by home assistance. Hopefully, the home assistance element will disappear and a scheme based more on the dignity of the person will be introduced in the very near future. That would be a very welcome development.

The whole question of rehabilitation and of allowances and grants for that purpose requires drive and I am grateful to find reference to this in the Minister's speech.

The auxiliary care allowance of £25 in respect of children who are handicapped mentally or otherwise is a very good thing and, to my personal knowledge, relieves a great deal of hardship. In many parts of the country there is still a waiting list in suitable homes for handicapped children. It is not possible to give the treatment and care that is available in these homes in their own homes but where children have to be kept at home the hardship involved for the parents was relieved by the introduction of the £25 monthly allowance.

I am grateful for the remarks of the Minister on the care of the mentally handicapped and mentally ill. Every Deputy who has spoken has stressed that it is an area to which particular consideration should be given. We are dealing here with people who cannot speak for themselves. An important barometer of the success of any Government's social legislation is the progress in the provision and improvement of services for the mentally handicapped and mentally ill.

I hope that the AnCO training courses for instructors of handicapped persons will enable courses to be provided which will facilitate handicapped persons in becoming more self-sufficient and independent.

The previous speaker was rather critical of the Minister in reference to a major White Paper on mental handicap and in regard to many of the aspirations that the Minister mentioned in his speech. I have nothing but welcome for the Minister's statement. The discussion document issued by the Fianna Fáil Party this morning does not justify Deputy Brennan's criticism of the Minister's activities and plans in relation to health. I have not been able to study the document in detail but I do not see anything new in it or anything inspiring or anything that has not been a feature of discussion documents on health for as long as I have been reading such documents. It states the obvious.

The Minister has stated that in real money terms there is a 6 per cent increase in expenditure in the three years that he has been in office. At this time that is a considerable achievement. The aim must be to provide free hospital service and a free health service for all.

I wish the Minister for Health well, and his Parliamentary Secretary and all those associated with the work that will have to be done to hasten the day when that service will be available. I sincerely hope that their ambitions will be realised in the current term of office of the Minister.

Dr. Gibbons

Comment has been made on the amount of money the Minister for Health has made available for the health services. There is obviously an increase in the amount of money. It works out at about 16 per cent. It is certainly not in keeping with the inflation which it has to meet over the coming year. To this extent there must be some fall-back in the services that will be available.

I was interested in the remark that we will see a 1½ per cent growth in the medical services over the coming year and that a cost/benefit analysis was being carried out in the Department. One would wish to see this developed, to see how one could estimate growth in a Department of Health or in the health services and how one could quantify cost/benefit, because of the variety of services involved and the different age-groups that have to be dealt with.

I have been a number of years in the medical service and I have seen changes, all of which have been progressive and of advantage to the persons who benefited by them. There is a change in attitude. When I first became a general practitioner the attitude at the time was to limit the services as much as possible and the medicines that were available were watched with a very careful financial eye. This did not matter very much because most of the medicines that were available were not very beneficial. At that time if a doctor wished to order a particular medicine in a specialised group he had to get special permission from the board of health. That is not now the case.

I have seen the growth of facilities made available. Now there are orthopaedic services, E. & T. services, maternity services, paediatric services and other more specialised services none of which were available as such 30 years ago. No doubt these services will continue to develop.

It is probably correct to say that a doctor's life is somewhat easier. In the old days a great deal of a doctor's time was taken up with domiciliary midwifery. This meant that the doctor could not plan his work. I notice that last year only 633 women were confined at home. This represents a big change. Also, doctors now have more organised time off, with the permission of the Department.

Debate adjourned.

Mr. Crinion

I should like to raise on the Adjournment Question No. 247 of last Tuesday.

An Ceann Comhairle

I will communicate with the Deputy.