Private Members' Business. - Health Contributions (Amendment) Bill, 1976: Second Stage.

I move:

"That the Bill be now read a Second Time."

The Health Contributions Act, 1971, established the principle that contributions towards the cost of services provided under Part IV of the Health Act, 1970, should be paid by persons who have limited eligibility for services under that part of the Act. The explanatory memorandum, which has been circulated with the Bill, defines the groups of persons who are required to pay contributions and the services to which they are entitled.

The present level of health contributions, at 26p per week, or £12 a year, were fixed with effect from 1st January, 1975. These are now, therefore, due to be increased, and I propose to fix them at 33p per week, or £15 per annum, effective from 1st April, 1976.

The increase proposed in this Bill takes account of the general increases in costs and incomes since the level of contributions were last debated and agreed in 1974.

When the original Bill was introduced in 1971 the then Minister made it clear that he was introducing the Bill "because of the urgent need to find another source of income besides rates and taxes to finance the heavy and growing burden of health costs". In further comment the Minister said that "the traditional sources for health finance must be supplemented in some other way and preferably in a way which can be shown to be directly related to the services concerned".

The financing problems which faced the health services in 1971 have not diminished. The reverse, unfortunately is the case. In the first instance, health service costs are rising rapidly. Health services are labour-intensive by their nature and rapidly increasing levels of pay in recent years have added very appreciably to costs. In addition, the demand and take-up rate for public health services is increasing at a fast rate, while technological and other innovations within the health care system itself have also speeded up the rate of increase of costs.

These and other factors have necessitated a rather rapid increase in health expenditure in recent years. In 1971-72, when health contributions were first introduced, public non-capital expenditure on our health services was £86 million. The Exchequer contribution was of the order of £45 million. In 1976, it is estimated that public non-capital expenditure on health care will rise to £262 million, while the Exchequer's contribution will increase to an estimated £242 million. In other words, the Exchequer's contribution to health care expenditure will have risen from 52 per cent to 92 per cent between 1971-72 and 1976.

This year, despite the competing claims of other public services, 18 per cent of non-capital Exchequer expenditure will be devoted to health care. This compares with a figure of 10.5 per cent in 1971. Part of the reason for the increased proportion devoted to health care is, of course, that the undertaking to remove health charges from the rates is being honoured and has practically been completed. In addition, however, major improvements in our health services have been achieved something which is demonstrated by the fact that expenditure on health has increased by some 16½ per cent in real terms during the last three years alone.

As a percentage of gross national product, public health expenditure has risen from 4.3 per cent in 1971-2 to about 6 per cent in the current year. In recent years, therefore, not only has public health expenditure been rising rapidly, but it has been rising at a considerably faster rate than the economy as a whole.

All of these statistics show clearly that health costs and health expenditure in our society are rising rapidly. Associated with this reality is the fact that public health expenditure is now funded almost entirely from the Exchequer. Local rates, which as recently as 1972-73 met over 40 per cent of the cost of health services, this year will meet only 1.8 per cent of the cost of these services.

In this situation, health contributions constitute, and will continue to constitute, an important source of revenue. Unless our general economic circumstances change to an extraordinary degree, we will have to continue to seek revenue from this source.

Having said that health contributions constitute an important element of revenue, I would like to point out, however, that the estimated receipts from this source—£10.2 million in the present year—represent only about 6 per cent of the estimated cost of providing limited eligibility services. It is clear that, from the beneficiaries' point of view, the new rates of contribution represent a very reasonable bargain in relation to the services which are available to them.

It will be clear from what I have said that health services, together with social welfare costs, impose a very heavy charge on our Exchequer. The combined provision for Exchequer grants in the 1976 non-capital supply services is about £485 million which represents about 36 per cent of the total Exchequer provision contained in the Estimates. The present system for financing health and social welfare services is being reviewed by an interdepartmental committee of representatives of the Departments of Health and Social Welfare. This committee have been making good progress and I expect that they will be in a position to submit their report by the summer. Before concluding my comments on the Bill, I would like to say that I will propose an increase in the present income limits for limited eligibility health services in the near future.

As the House is aware, while there is no income limit for insured manual workers at present, there is an income limit of £2,250 per annum in the case of insured non-manual workers and an income limit of £1,600 per annum in the case of all other adults, except farmers. In the case of farmers, those with farm valuations of £60 or less are in the limited eligibility group.

I had hoped to do away with an anomaly between insured manual workers and all others, by providing free hospital care to all. This has not been possible to date, however, as the House is aware. The present income limits of £2,250 and £1,600 were fixed in April, 1974, and October, 1971, respectively. They are now due to be increased in pursuance of the normal practice of increasing income limits from time to time, in line with increases in incomes generally.

Unless the existing income limits are increased in the near future, a very large number of people, who are now entitled to limited eligibility health services, will cease to be eligible. Indeed, in the case of insured non-manual female employees, a significant number of them will become ineligible from 5th July next, unless the present income limit is increased. In all, 85,000 people will become ineligible by the end of this year, unless the income limits are increased in line with income increases since the present limits were fixed.

I propose to submit to the Houses of the Oireachtas for approval draft regulations which would fix a new limit of £3,000 per annum, as soon as present consultations with the medical profession are completed. This should be in a matter of weeks. If these regulations are approved and made, all those now entitled to limited eligibility health services will remain entitled and an estimated 85 per cent of the population will remain eligible for free hospital care.

In conclusion, let me say that this Bill proposes no more than that the present health contributions be increased in line with incomes and costs generally. The proposals it contains represent no more than the normal periodic increase in contributions in line with inflation.

I commend it to the House.

In this legislation the Minister for Health proposes to increase the health contribution by 27 or 28 per cent. The general public have had so many savage increases in taxes and charges imposed upon them by this Government that I believe this increase is unlikely to attract the attention and the opposition it would in normal circumstances and with a normal type of financial administration. I believe the general public have become anaesthetised against impositions of this sort. Many of them have simply given up the struggle. They no longer try to order their financial affairs in any planned fashion. There is a large section of the community these days who simply live from day to day. It is, however, important in dealing with this legislation that we, on this side of the House, direct the attention of the public clearly to precisely what is involved and to explain the nature of these increased charges and the real purpose for which they are intended.

The House and the general public should clearly understand that this increase in charges which the Minister now puts before the House will not go towards improving our health services in any way. The money which will be raised by this legislation and by these increases will not be used to provide any new services, to improve standards, to provide any extra facilities or to make improvements of any kind in our health services. Neither those people who will have to pay these contributions nor anybody else will benefit in the slightest degree in regard to the health services provided for them by this increase in contributions. This is not a health Bill; it is a taxation measure. As such, it should have been included in the budget package of taxes last January. The extra amount these increases will bring in, £1.7 million, has already been taken fully into account in the budget arithmetic. It is important the House understand that.

The amount involved here has been taken credit for as part of the budget revenue. It has already been fully absorbed in meeting the budgetary situation. These moneys will not be available to improve in any way the health services for those who will be called upon to pay them. In fact, this money will be handed over completely to the Exchequer as a budgetary measure. As I said, this is a taxation measure.

Even though the credit for this £1.7 million was taken in the budget, the Minister for Finance in introducing the budget did not mention this increase at all. It was not until the Book of Estimates came out and we saw there the figure for Appropriations-in-Aid of the Health Estimate, £10.2 million, that it was clear that this money which is now being sought by the Minister by way of this legislation, had already been fully credited in the budget arithmetic. That is the way this Government conduct their financial business. They resort to petty deceits I suggest that it would have been proper for the Minister for Finance in introducing the budget to say clearly and distinctly that he had already taken account in his budget arithmetic of these increases which the Minister is now bringing before us.

Closely related to this legislation is the vexed question of the exclusion of non-manual workers with incomes in excess of £2,250 a year from limited eligibility benefits. Persons in this category have been specifically excluded by the Minister for Health, by means of an order he made in 1974, from the very important benefits involved, hospital in-patient, specialist out-patient, maternity and child service, and the drug subsidy scheme. These services are fully available to all insured manual workers. Of course, this is an administrative anomaly and is guaranteed, as all administrative anomalies are, to cause friction and a certain sense of grievance among a large section of the population.

It is absurd to ask a person in one type of employment to accept a situation in which he is denied a range of benefits available to a fellow worker with the same income and in the same family circumstances merely because he is in a different type of employment. This situation should be rationalised. Whatever may be the level of income decided on, it must be of universal application. This anachronistic division can no longer be justified. Further, the income level decided on must be a practical one because there is no point in making available in theory these limited eligibility services to a section of the public if in practice they cannot be provided by the hospitals and the medical profession. That is the crux of the matter. The principle of practicability should govern every extension of the health services. In other words, extensions should always be related immediately and directly to the resources available. It is because of his consistent refusal to adhere to that principle that the Minister has plunged our entire health administration into its present state of division.

From the Minister's speech it is not clear whether he is proposing to deal with this anomalous situation. From a quick reading of the speech, a copy of which the Minister so courteously arranged to have me supplied with, it seems that he does not propose to make any change in the situation of non-manual workers who earn more than whatever may be the specified limit. Therefore, I should like the Minister to clear up that point early on in the discussion because it is stated in his speech and I quote:

I propose to submit to the Houses of the Oireachtas for approval draft regulations which would fix a new limit of £3,000 per annum, as soon as present consultations with the medical profession are completed. This should be in a matter of weeks. If these regulations are approved and made, all those now entitled to limited eligibility health services will remain entitled and an estimated 85 per cent of the population will remain eligible for free hospital care.

I take it from that wording that if the new income limit of £3,000 per annum is introduced, non-manual workers, insured persons in excess of that figure, will still be ineligible for limited eligibility benefits. If that is so, the Minister is perpetuating this anomaly, whereas I would have expected that in bringing this legislation before the House he would have given us some idea of the numbers involved and how many insured persons there are with incomes in excess of £2,250 who are excluded by reason of their being non-manual workers. What is the extent of this problem? A very large section of the working population have grievances in this regard.

I have tabled an amendment for Committee Stage the intention of which is to ensure that, whatever the income limit, it shall be of universal application. In other words, this anomalous distinction between manual and non-manual workers will disappear.

This differentiation may be unconstitutional as somebody has suggested to me but I am never disposed to making prognostications as to what may or may not be constitutional. However, should anybody wish to test the constitutionality of the provision which leads to this anomaly, I expect he would have a very good case.

I suggest that the Minister has caused a great deal of confusion in the public mind by his erratic behaviour and statements in relation to a number of these matters. There was the blithe announcement of a free hospital service for all and even long after it had become abundantly clear that this was not a practical proposition, the Minister persisted in maintaining the fiction. Indeed, he refers to it again today in his speech. In addition, while professing a desire to provide a better service free of charge to an increasing sector of the public, he has acquiesced this year in what must be relatively the most severe cut-back in the national budgetary provision for the health services in modern times.

At a time when our hospitals are already stretched to capacity with existing numbers and have had drastic reductions imposed on their operating budgets, the Minister proposes an increase in the numbers of persons eligible. Recently he increased substantially the cost of private and semi-private hospital accommodation thereby throwing an additional number of persons into the public sector persons who otherwise might have been prepared to pay for private or semi-private accommodation but who will no longer be encouraged to do that because of these increases but will add to the queue for scarce accommodation in the public wards.

The general situation in regard to the financing of our health services this year is chaotic. There are serious doubts as to the capacity of the hospitals to sustain an acceptable level of essential services throughout the whole year in their regions. Similar fears exist in the voluntary hospitals, the allocations for which fall far short of their budget requirements in many instances. There are real indications that the amount provided for the general medical service is inadequate to permit the service to provide a full service for medical card holders throughout the year.

I should like the Minister in replying to advert in particular to that aspect of the financing of the health services this year. Is the amount he has provided in the Estimate for the general medical services payments board adequate to meet the estimated expenditure of that board during the coming year or will it involve a serious cutback in the general medical service as provided for medical card holders? It is clear that unless we are prepared to accept a serious reduction in the level of the health care provided for a large section of the general public this year, additional funds must be provided by the Exchequer. The Minister must face up to that reality.

Indeed, the Government as a whole must face the problem because it is at the Government table ultimately that fundamental priorities of this kind must be sorted out. The Minister must insist on the Government making a decision now to provide the additional funds that are needed to maintain the health services at an adequate level throughout 1976. If a decision is taken now and the necessary additional allocations announced soon to the regional health boards, the voluntary hospitals and the general medical services payments board, then serious dislocation of our health services can be avoided. If this does not take place, I am afraid that programmes of economy and cutbacks will have to be undertaken and measures will have to be taken by boards and authorities which will cause widespread hardship and suffering to the people who rely on those services.

It is very difficult for anyone outside the official establishment to quantify what additional amount is required to finance our health services this year. From my own limited knowledge and using whatever information I can assemble, I believe that the regional health boards between them would require an extra £8 million this year if they are to maintain their services at a satisfactory and adequate level.

Each health board.

No, between them. That is the calculation I made to the best of my ability. I have taken them all together and put particular emphasis on the Eastern Health Board and have looked at the others and the difference between their budgets and what has been allocated to them. I believe that the eight regional health boards between them would require an extra £8 million this year to provide adequate health services at the same level as existed during 1975.

I believe that another £7 million to £8 million would be required for the voluntary hospitals and the general medical services payments board. This means that in the region of £15 million would be required in the Estimate for the Department of Health to enable our health services to get through this year without serious disruption. It is very difficult for someone who has not access to the official figures, information and statistics to try to quantify the situation. The best estimate I can make of it is that between the health boards, the voluntary hospitals and the general medical services payments board somewhere in the region of £15 million would make the situation reasonably satisfactory. I suggest that the Minister should try to get it across to the Government, where the ultimate decision in these matters lies, that that additional money must be provided by the Exchequer. I also want to make it clear that it is not my responsibility to propose how those funds should be provided as I have not the details of budgetary policy and the different demands and pressures which would enable me to decide where that £15 million is to come from. That is the responsibility of the Government.

I want to make it clear that I am not demanding any new services. This Government, and particularly the Taoiseach and the Minister for Finance, continually resort to the argument in relation to the Opposition of saying that if we demand some new service, some new facility or some additional improvement we must state where the money is to come from. I do not think that is a valid argument but it is one the Government use ad nauseam. I am not asking for any new service so that argument does not apply in relation to what I am saying. I am only asking that the existing services, which were there throughout 1975, which were built up to a certain level over the years and were maintained at a certain level during 1975, be maintained. I am only asking that an additional amount of money be provided by the Exchequer to enable those services to be maintained throughout 1976 at that level.

I believe these additional allocations must be made. It is my duty in Opposition to point that out to the Minister, the House and the general public. At this stage of 1976 unless those funds are provided our health services cannot be maintained at an acceptable level during this year. It is not for me to say if that would involve a rearrangement of existing budgetary provisions or whether it would involve some other measures. I believe this could be done within the confines of existing budgetary provisions. I admit I have not the information to assert that positively or definitively. Whatever else has to be sacrificed, whatever other economies must be made, hospitalisation of the sick, medical care and attention for those in need are basic requirements in any civilised community and any rearrangement of the budgetary provisions that have to be made to enable those essentials to be provided must be and should be made now.

I want to make it clear that I am not purporting to the House to have the knowledge which would enable me to make any positive assertion about this matter but I want to put it before the Minister. Perhaps a review should be made of the structure of the regional health boards. I hope I am not one of those people who just look at any organisation and say that it is top heavy, unwieldy and bureaucratic. I believe the regional health boards have done a good job in developing services, in exploring needs and in endeavouring to provide new programmes to meet needs but whether or not there is excessive cost in the bureaucracy of the health boards is, perhaps, something that might be examined at this stage. I believe it is an area which would merit examination in the context of the rearrangement of financial provisions which I am suggesting to the Minister.

I cannot escape, in that connection, a conclusion that there is a good deal of covering up going on between the health boards and the Department of Health over the budgets for 1976. As I pointed out during the discussion on the Private Members' motion recently the allocations made by the Department of Health fell far short of the budgets prepared by the health boards and submitted by them. The shortfalls range from £300,000 approximately in one case up to £3.7 million in the case of the Eastern Health Board. The chief executive officers of the different boards, as was their duty, submitted reports to their respective boards indicating the extent of the shortfalls and outlining proposals for cutbacks and reductions which the allocations would force them to adopt. That process took place from January through February in the case of all the boards. The chief executive officer and his management team pointed out to each board what the deficit was and how he thought it could be met. Those proposals which were put forward by the chief executive officers varied in content and severity from board to board but they all followed the same general pattern. Their decisions were to restrict the issue of medical cards, restrict visiting and prescribing by doctors for patients on the general medical service register, cut down or eliminate the transport service for patients to hospitals and other centres, cut back community services like meals on wheels, home help, free milk, dental services and so on; cut down on repairs and maintenance, on heating in homes and hospitals and reduce different benefits under their control; cut down on the child medical examination service in the schools.

All of these and many other proposals were made by different executive teams to different boards throughout the country. One of the most drastic proposals in this regard was put forward by the Eastern Health Board in regard to St. Loman's Hospital. There, the suggestions put forward by the executives and the programme managers bordered on the ridiculous. There were proposals such as removing corn flakes from the breakfast menu, making desserts simpler, cutting down on minerals and soft drinks, cutting out newspapers for patients and stopping taking patients to cinemas. Various other almost ridiculous economies of that sort were proposed for the unfortunate inmates of St. Loman's Hospital, people who could not fight for their own rights in this matter. The Minister has since tried to deny that the Eastern Health Board actually proposed these reductions, cutbacks and economies but they were seriously put forward in St. Loman's by the management and probably they are still in operation.

Throughout the country in the different areas of responsibility of the boards all sorts of economies, cut-backs and reductions were put forward. Subsequently, discussions were held between the managements of the different boards and teams from the Department of Health and, arising out of these discussions, we were led to believe that the deficits had been eliminated and that the boards would be able to manage within the allocations that had been made. I find that very suspicious. So far as I am concerned it is all very dubious. Were the budgets, as originally submitted, not genuine? Were they not prepared on a prudent, economic basis? Were the executives in the health boards guilty of irresponsible, careless budgeting and financing? If the team of officials from the Department of Health could come along and revise the budgets so that the deficits disappeared, surely something was wrong in the first instance?

In fact, I do not believe that the executives and the management teams submitted inflated, irresponsible budgets in the first instance which were subsequently pared down by the team of experts from the Department of Health so that the deficits could disappear. I do not think that happened. I think the deficits are still there in reality. They have been eliminated on paper and I think this is particularly so in the case of the Eastern Health Board. There is a great deal of bluff and covering up going on in regard to this matter. The real deficits are still there and they will manifest themselves as the year goes on. These cut-backs and deductions will take place. It is all just a propaganda exercise resulting I am afraid from collusion between the Department of Health and the executives of the health boards. So far as I am concerned at this stage until I am satisfied otherwise there is a great big question mark hanging over this situation.

It is a very serious situation. All those concerned should know that the regional health boards structure has its very determined critics throughout the country, people who have never accepted the concept and who believe it is not the best solution to our health administration problems. If it is going to be demonstrated that a big deceptive exercise has been engaged in throughout the health boards with the Department of Health, those critics of the health board structure will be greatly strengthened in their opinions and in their doubts about the value of the whole regional health boards structure.

The situation that has arisen, that of a very inadequate allocation having been made in the budget for health services this year, is a reality. I have tried to quantify the overall shortfall as somewhere in the region of £15 million. I may be wrong about that but there is no doubt that there is a serious shortfall in the provision made by the Government. However, it has this possible side advantage, namely, that it serves to focus the attention of all of us on the question of the future development of our health services and their financing.

The Minister made a very passing reference to that in his speech when he referred to the fact that the present system for financing health and social welfare services is being reviewed by an inter-departmental committee of representatives of the Departments of Health and Social Welfare. That is very interesting. There is an inter-departmental committee of the Departments of Health and Social Welfare dealing with the finances of the health services but there are no representatives from the Department of Finance. Surely this is an absurdity. How can there be any inter-departmental investigation into the financing of the health services without someone from the Department of Finance being present? Is this a political gimmick? Is it just because health and social welfare are under the same Minister? Of course he has a Labour Parliamentary Secretary in charge of social welfare. Is this a nice, friendly, Labour exercise? In any event, I do not believe that an inter-departmental committee is the appropriate machinery in this instance. Certainly an inter-departmental committee that does not include a representative from the Department of Finance is meaningless.

This serious situation in regard to the health services and their financing must dictate to us that we should look at the health services as a whole in total, their future development, the extent to which they are being developed and how that development will be financed. We must ask ourselves whether it is possible to provide for the development of our health services on a planned, orderly basis and to have that development financed in a way that would make those services either totally immune from budgetary crises from time to time or else put them in a situation where they would be only marginally affected. That is the key question we must face up to. Can we so devise the financing of our health services that if there is a budgetary crisis which involves the settling of a particular budgetary policy for economic or financial reasons that that budgetary crisis will leave the health services comparatively untouched? Must we go on with the situation where a budgetary crisis, brought about by economic or financial causes and with nothing to do with health, causes this serious dislocation of the health services?

In that context I suggest that we must maintain a sense of proportion here. We must realise that we are not now having to deal with a situation, as some people suggest we are, where the cost of our health services has escalated to an unmanageable level in relation to national economic resources. It is important that we realise that. Of course, we have the problem of providing the necessary finance for our health services but I do not think we should panic or that we should accept the argument some people put forward that it has got out of all control and has become unmanageable and can no longer be rationally related to the resources which we can provide. I calculated that not more than £15 million extra would be needed this year to maintain all our existing services at a reasonably satisfactory level throughout the year. In absolute terms that is a large sum but it is not a figure of intolerable magnitude in relation to an overall expenditure in this year's budget of £1¾ billion which is the total of our non-capital budgetary expenditure in 1976. When one looks at the extra amount I am suggesting as being necessary to provide adequate health services this year it is not all that absurd in relation to that overall figure.

I do not think we need to be totally intimidated in this House or in the inter-departmental committee by the level of our health expenditure in relation to our GNP or our total budget at this stage. We have not yet got into an uncontrollable nightmare situation as they have in other countries. I believe that a comprehensive set of decisions are necessary at this stage on the shape of things to come if we are not going to run the danger of getting into that sort of nightmare uncontrollable situation. We must decide the fundamental issues about the sort of health service we are going to have and the rate at which we are going to progress towards that health service.

A health service for this country must be designed for our own needs. It must be suited to our own circumstances and be directly related to our economic and financial capacity. It is on those grounds that I have on occasions attacked the Minister. In my view I was justified in doing so. I believe that the Minister is inclined to import ideas here; he is more inclined to look at some outside system which he admires and to transplant it in its entirety into our circumstances. I do not think that will work and that is where we have to have good sound basic thinking in regard to the whole future of our health services. We are a very special sort of community. First, we have very special population characteristics which are, perhaps, unique in western Europe. Our population is dispersed throughout the country in a way which is different from most other European countries. Our economic circumstances are different and, unfortunately our GNP and our per capita income are below European level. We have different social traditions and a different outlook in many areas to other countries.

All these things seem to dictate that we must design, evolve and work towards a health service which will be suited to our own circumstances, conditions and needs and, above all, which we will be able to afford to pay for. I suggest that in the evolution of such a health service there are a number of guidelines we should follow. It must be recognised that the provision of a free health service generates a continually increasing demand for that service. Perhaps that is not something that was fully understood and realised a decade ago but it has now become increasingly obvious to everybody who studies the situation. If in the area of health a free service is provided the provision of that service generates a continually increasing demand for it. That is an important factor which must be kept in mind in any planning of the evolution and development of a health service.

A very important aspect of our thinking in this regard should be that an increasing emphasis must be placed on preventive medicine, on health education, on physical fitness and on the question of dealing with drugs, alcohol and tobacco. In all these areas if we place an increasing emphasis immediately it will ultimately go to help in dealing with the financial implications of the entire health service. Money spent in these areas of preventive medicine will ultimately bring down the overall cost of health to the community. In that connection it is important to realise what happened in Britain in regard to the health service there. The idealists and the visionaries in the early days of that service sincerely believed that if a comprehensive national health service was brought in ultimately the very operation of that health service would be such that it would be possible to eliminate, to a great extent, illness and disease in the community and, eventually, the wholecost of health would come down. Of course, that has turned out to be a tragic illusion. In fact, the inevitable law I mentioned earlier is the one which is manifesting itself instead, namely, the very provision of a free health service generates an almost insatiable demand for that service as time goes on.

There must be a major shift from hospital to community medicine. We must try to get more medical attention provided in the local communities. That leads on to another principle to which we should subscribe, the need to build up the general medical service. I cannot understand the Minister's approach in this regard. His mind seems to be fastened on this business of free hospital services for all and he has set his mind against the progressive extension of the general medical service. That is a fundamental disagreement between the Minister and this side of the House. We believe that it is in the general medical service that extension should come. That is related to the principle of trying to have more medical and health care provided in the community as distinct from the hospital. There is no doubt that that would in time result in a lesser burden on the community in regard to the finance that has to be provided for health services.

Another aspect of this is of course the principle which I believe we must adhere to, that is, that there is a very considerable reservoir of resources available in the private sector and in voluntary organisations which must be fully availed of and not ignored and discouraged as at present. In that connection I want just to mention an instance which I raised here a couple of times at Question Time with the Minister of the Ballindine Rehabilitation Centre provided by the Disabled Drivers' Association. There is a case where a voluntary orginisation by their own efforts have done a magnificent job in providing a centre for rehabilitation and training of their members. They have been tremendously successful in raising money and in getting on with the provision of this centre. The Minister has set his face against their efforts. He refuses to entertain any question of giving them a grant and in fact one detects a general air of hostility on the Minister's part towards that activity. This is something I cannot understand.

Our resources are scarce enough between what the general body of taxpayers can provide through the State and what can come from private sources and voluntary organisations. If we are ever to get anywhere near a reasonable level of a satisfactory comprehensive health service for all the people we will have to use every possible resource. We should not let ourselves have any blind spots about a particular area and if a voluntary organisation can do a job, encourage them to do it as in the case of the Disabled Drivers' Association.

Alternatively, if in the private hospitals and nursing homes there are facilities and services available why not avail of them, why try to discourage these people from providing the services? Certainly, I want to say that in our case on this side of the House, when it is our responsibility to propound a comprehensive health service we will certainly have as a central principle the full utilisation of all the resources which can be provided in the private sector and by voluntary organisations.

Also, I believe that the principle of insurance must be availed of to the greatest possible extent. It is becoming increasingly clear in modern communities that it is only through voluntary personal insurance that a really satisfactory standard of health can be provided for a large section of the community. The value of voluntary health insurance in this country has been proved beyond any doubt. The Voluntary Health Insurance Board is the most successful State organisation ever established in this country. It has proved that this is a way in which a satisfactory level of health services can be provided for a particular section of the community and I believe that part of the answer to a satisfactory health service for the future lies in that direction, bringing more and more people into the framework of voluntary health insurance.

As I said, these are some indications of the way in which I believe we should proceed. I believe that there is a very real danger at this stage that an appropriate level of services is not going to be provided in the community where they are needed because of a shortcoming in the financial provisions made by the Minister and the Government for health this year, and I believe the first thing to do is for the Minister to persuade the Government to make available the additional moneys which are needed to enable our services to be maintained at a satisfactory level in 1976. That is the first thing which I want to impress upon the Minister.

The second thing I want to say is that this situation in health which has arisen because of the budgetary crisis which the Minister for Finance has brought upon all of us, should be used to focus our attention on the need to plan our health services for the future, plan for their development and plan for their financing and I believe that that planning is needed now. There is still time to do it. There is still time to develop a programme of development for health services which would be sensible and rational, which would be suitable to our needs and which would be within our capacity to pay for, particularly if built up upon the lines I have very briefly suggested. We still have time to do that. I believe we should do it very soon. I do not believe an inter-departmental committee of officials of the Department of Health and the Department of Social Welfare is the way to do it. There are other vehicles and approaches to do that job. I do not expect that this Government or this Minister is going to do it but I can assure the Minister that when it is our turn we will tackle this thing in a sensible, rational, progressive-minded fashion.

I listened with some interest to Deputy Haughey's contribution. I gather his argument is that he is looking for another £15 million which he says is the figure required to keep the health service going but I do not know that he approached the subject from the point of view of any constructive economies that should be made. While he prefaced his remarks by saying that he had not got the facts that would enable him to make suggestions I would have imagined from the very ample brief which he has been supplied with that something on that line might have been forthcoming. We have to realise that health is not just a luxury; it is a necessity and as such a health service is an absolute necessity in a civilised society.

Deputy Haughey made a very relevant point when he said that a free health service generates increasing demand for services. This is all too evident. Might I give an interesting figure in relation to how costings can escalate in accordance with the demands made on health services? In relation to the dispensation and consumption of drugs as dispensed by doctors—I am talking about ethical drugs on doctor's prescription—two thirds of the entire drug consumption is consumed by one-third of the population and that one-third of the population are entitled to the general medical service. These figures bear out what Deputy Haughey said. They bear out another theory, that there seems to be a certain over-consumption and over-prescribing of drugs in a certain section of our society.

If those figures which I have been given are correct it would seem to me that the paying patient is able to have his health for lesser drug consumption than the patient who gets it free. This appears to me to indicate a certain abuse of drugs. I am talking about drugs handed across the counter. My own experience and that of others is that drugs are prescribed and not used. One can go into a house where there is a general medical service card and see drugs lying around. There is considerable abuse and it was right for the Department to issue a recommendation to health boards to tighten up in regard to prescribing drugs so far as they could.

What positive steps can be taken? I suggest we are overdue a national formulary. I know there will be objections because certain people will say certain drugs are incompatible in the case of certain people but medical advice can be obtained and if a person wants to go outside the national formulary or a doctor wants to prescribe outside of it, then let there be a charge. We are not in a position to pay for all we want in the way of health services. It has to be a mix, partly contributory and partly free, partly State-orientated and partly assisted by the private sector. If what I suggest is done, there should be a considerable saving in costs.

One need only look at a well-known publication on every doctor's desk which lists the drugs that can be obtained, their dosage, and price. In this publication I have seen two drugs for an upper respiratory infection, one costing £1.50 and the other £6. That was some time ago. I happened to go into a house to find that two doctors had been treating members of the family and one had prescribed the £1.50 drug and the other had prescribed the £6 drug. The family were having a feast of pills. They were trying each others. It was during the flu epidemic. With this kind of abuse one might as well write off the health services because there will be a lack of control and the end result will be that people will harm themselves. It is time the medical profession took cognisance of this. We are all paying for these abuses irrespective of whether we are insured workers or paying from our own pockets. It is adding a tremendous amount to the cost of the health services. I have been advised by an executive in the health service that it is just short of scandalous the abuse that has taken place in the ordering and prescribing of drugs. I know it is not easy at times for a doctor to tell a patient just to go to bed and keep warm for three or four days and he will be all right. The doctor feels he must prescribe. Indeed, very often patients demand a prescription and even name the particular antibiotic. When we get to that stage the doctor ceases to be a medical adviser.

I also believe that there is considerable abuse of out-patient departments in our hospitals. That I put at the door of the doctors who do not like working after certain hours in the evening and, if there has to be a repeat injection, they send the patient to the out-patient department. This adds considerably to the cost of hospital services.

I would like to make one plea for one section of our community which has not been referred to so far. I refer to farmers with abnormally high valuations like the farmers in the Macamore area in Wexford. The valuations there are quite scandalous. In many cases the valuation is over £1 per acre. Anybody under 70 acres should be eligible for certain services. I know they pay a yearly sum but I know the present position is having an adverse effect because their children are not getting the treatment they should. We are neither unChristian nor uncharitable but there does come a time when parents simply have not got the money to meet the expense of hospital treatment for their children. There is a good deal to be said for adopting the Isle of Man approach where all children, be they the children of paupers or millionaires, are entitled to free medical services. We should be thinking along these lines.

Deputy Haughey referred to the role of the private hospital. There should be a better per capita subvention to the private nursing home and hospital because these are taking a great part of the load off the general hospitals in making beds available for patients. It is interesting to note that in England an increasing number of those entitled to free hospital services are now availing of treatment in private institutions. Part of the reason is that they have to queue for the free service. When a person is sick we should do everything possible to avoid a queue taking place and patients having to wait weeks or months for treatment. We should also provide drugs free for those suffering from terminal illnesses no matter what their circumstances may be. I am aware of cases where such people would not avail of these drugs because they felt it would be a waste of money and they did not want to burden their families with increased medical costs but in this day and age if people have this hardship and this tragedy before them, they should be able to go to the grave with an easy mind without burdening their family. There is provision for certain conditions to be dealt with but there is room for further enlargement of the categories that qualify for free medicine. I do not know if cancer qualifies, but if not I think it should. It is obviously a terminal case and hospitalisation in those circumstances can be very expensive.

There is a lot to be said also for not using the absolute rule in respect of medical cards. There should be a graded medical card whereby a person with a condition would be entitled to free service up to a certain amount. In Australia, for instance, people have a per capita allowance per year for dental services and if it goes beyond that they pay. At least it gives them a start, and it is given by way of negative allowance against their tax bill. We have something of the same sort here if medical fees go beyond £50. There is a taxation allowance in that regard but very few people know about that, as far as I can gather.

There are many other matters that the Minister just touched on. There are new techniques in hospitals that are giving rise to greatly increased costs. It is interesting to note that there is only approximately a 4 per cent improvement in cardiac cases with the intensive care units. They provide only another 4 per cent with life, but it is an essential 4 per cent. It is a very expensive service but it has to be provided to keep standards right.

Another service provided is the medi-scan service. Many people are complaining at the considerable cost, but it is a great thing to know that in 24 hours you can have a medi-scan. You go into hospital for the night and they work through the night on you even in your sleep. These are modern phenomena in the hospital service that require a very skilled team. It is an around-the-clock service and it is very costly. Naturally enough, a large part of this has to be met by State subvention. It is a good thing that the ratepayers do not have to pay for these services as they used to. It has been a great relief, and in my own constituency transferring it to the Exchequer probably means relief of about £4 in the pound.

While it might be easy to talk about providing another £15 million for propping up the health services, we have to look at ways of achieving economies, and we might have to consider a prescription charge for certain sections of society. If a service is being abused by some people in the way I have referred to, possibly a charge might bring them somewhat to their senses, as it has gone completely beyond a reasonable attitude. There is considerable abuse of the drug system and it is about time, in the interest of good health for the nation that something was done. I am not speaking just from what I am told. I am speaking from what I have observed. I come from a medical family and I am aware of what is happening in this field.

I do not agree with Deputy Haughey in all that he says. One thing I take exception to is his comment that on his side of the House they lay emphasis on the general medical service rather than on hospital care for all. The most expensive element of medicine is hospitalisation. Most of us are in hospital only once or twice in a lifetime, but it is something that a normal person has to be very wealthy to carry himself. Were it not for the voluntary health service many people would have to keep a very large nest egg, if they had a family, to face the medical charges that now have to be met when people go to hospital. We can all be very grateful to the voluntary health service for what they have done in that regard. I am one of the people within that category. I do not know what I would do if there was not such a service for people like myself and those who do not qualify for the £12 or £15 payment per annum. I am not decrying the voluntary health service when I say that comparing what one pays towards that service with what people are asked to pay under this service, it is fantastic that it can be done so cheaply, that there is such a small contribution asked of people. It is a well worthwhile investment for people and I do not think they should complain about the small increase that is asked for in this Bill having regard to the greatly escalated costings that have to be faced in the health service. What we should be directing ourselves to is the avoidance of waste in the health service, and if we did that we might be able to provide a much better service.

In dealing with this measure before the House for increasing health contributions, I am baffled as to how the Minister was going to give a free for all service when he is now unable to provide the necessary finances to keep the present programme in operation. All of the health boards had to make cutbacks in the estimates. Some of the health boards are unable to make the cut-backs, and the Midland Health Board cannot do it without causing hardship.

I do not know whether the estimates the health boards sent up to the Department were wrongly calculated, but from the information I have in the Midland Health Board area there is a general tightening up in all the services in operation. There is going to be a tightening up as regards medical card holders. The personnel have been told to cut down on bed clothing, laundry work, drugs and also in regard to the menu. If that takes place, I cannot see any great saving in that line because in the Midland Health Board region there was never any such wastage. Transport is going to be curtailed also. I do not know of any abuse in that regard.

In the estimates sent to the Department of Health by the health boards, I do not think they allowed for at least 20 per cent inflation when they were paring down those estimates. If there is 20 per cent inflation, that will mean that even if the additional money is provided for the health boards, they will have to come back in the middle of this year and look for more money from the Department of Health. This is the kernel of the problem.

As I was saying earlier, others may be better qualified than I to speak on this aspect but I would like anybody from the Government benches to tell me how you can give a free for all health service if you are not able to maintain the existing service at last year's level. That is all I am asking. Now the Minister is trying to bulldoze a health scheme through this House which will provide a free for all health service.

I want to talk now about the voluntary hospitals. The Minister allowed them to increase their charges very substantially. What I see happening here is that patients, instead of going in semi-private or private may now decide to go in public. That will bring additional pressures on the voluntary hospitals. As far as I know, notices have issued from the voluntary hospitals to the effect that they will have to watch their overtime, replacements during vacations, sick leave and so forth.

Deputy Esmonde spoke about drug abuse and the over-prescribing of drugs. This may happen in the area of mental illness. We all know that that type of illness is very complex. There may be some misuse of drugs in that area and that could be brought about when the patients attend the out-clinics. They will take home the drugs they get there, or they may put the drugs in presses or the people in charge in the homes are allowing that to happen. In the ordinary way, I do not believe doctors are putting extra expense on the health boards.

Reference was also made, inside and outside the House, to the fact that people with medical cards are abusing them and that the medical profession are calling on them too often. That is a problem. If a doctor does not attend a patient when he is called and something happens to the patient, who is in trouble? I am not backing the doctors but this is a fact which must be cleared up. Since I came into this House several questions were put down to Ministers for Health about an ambulance being slow to come to a patient, to an accident or something happening in a hospital which should not have happened. I cannot say whether that was right or wrong but this is the awkward position in which the medical profession find themselves. As far as I know they are carrying out their duties to the best of their ability.

There has been talk about prescriptions being expensive and cheaper drugs could be used instead of expensive drugs. I do not know enough about this to speak on it and I do not intend to. In my region the medical profession and the chemists carry out their jobs to the best of their ability.

Some homes which could take patients from surgical wards have not been paid the grants they should have got from the Department. I said this over the years. This has put an extra burden on the county hospitals. I am referring specifically to my own county hospital when I say that. Some of our wards are full. Some of our aged have nowhere to go and others cannot go home because of circumstances outside their control. Not alone is this happening in the midlands but it is happening all over the country. The care of the aged is a very big problem at the moment. People are not prepared to look after them. Some people do not want to care for these people but they want to take all they have and use it. They want everything they can get from the health boards and blame everybody else if they cannot get them into suitable homes. They do not want to pay for them. There is a limit to what we can do in that line. If we got a little more help from the public at large, it could relieve the burden on our institutions.

For quite some time I have been harping on home care allowances from the health boards. In my opinion they are on the skimpy side and are no help. An allowance of £2 or £3 is no good. When cases are being examined by the boards their rules are found to be too strict. It is my contention that if the health boards paid a little extra towards the care of the aged in their own homes, our institutions for senior citizens would not be called on to look after so many of these people. We know, too, that it costs about £25 per week to keep a person in one of these institutions. Would it not be better that the Department direct the health boards to be more flexible in the allocation of moneys towards such items as home care allowance, fuel and so on? So far as the Midland Health Board are concerned there is much stringency of late in this regard and this situation is imposing an extra burden on the welfare homes.

Recently the CEO of the Midland Health Board stated that they will have to keep within the estimate approved by the Department. I do not know how this can be accomplished especially when, recently, they could manage only to reduce their estimate by about £500,000. I do not know how they achieved that but now they must cut their spending by about another £400,000 and up to a week ago at any rate there was no sign of that money being made available by the Department. This can mean only a cutback in services and, unfortunately, the cutbacks start usually with the weaker sections of the community who are unable to defend themselves.

It is not my intention to be too critical of the health boards but it is said in some quarters that they are top heavy on the administration side with one fellow looking after another so that, one would not know where he stands. It would be worthwhile if economies could be effected at that level. If the health boards are not given the money they require such services as meals on wheels and the care of the aged generally will be reduced. I understand that throughout the country the heads of geriatric units are in the process of carrying out examinations for the purpose of determining which patients might be sent home but, unfortunately, some of these people have no homes to go to. I had such a case last year.

It is difficult to visualise the Minister thinking in terms of implementing a free for all hospital service when he is unable to maintain the level of last year's services. So far as I am aware the health boards are being left short by about £10 million and I suspect that by the end of the year the shortfall will be in the region of £15 million. If this money is not made up, there must be cutbacks.

Regarding eligibility for medical cards, I would suggest including in that category regardless of income all those suffering from cancer, a disease which is very prevalent nowadays.

One of the greatest organisations to be set up here was the VHI. This body have been doing wonderful work and great credit is due to whoever instigated their establishment.

It was set up by a former colleague, Mr. Tom O'Higgins.

That is so. Those who were not members of the VHI should consider becoming members. The average contribution is £1 per week which, in terms of today's values, is not a great amount. Since the Department of Health cannot provide these medical services, the people must think in terms of how best they can provide them for themselves and that is why I advocate membership of the VHI.

I understand, too, that school medical examinations are being curtailed and that this will have an adverse effect in so far as our children are concerned. As I said earlier, in making an attack on any health service, the Minister is getting into deep water although I am not blaming him entirely because he must have sanction for expenditure from the Minister for Finance and from the Government as a whole. The cutbacks that will result from the shortage of money must have a serious effect because it is generally the people at the bottom of the ladder who suffer. They will affect the care of the aged, medical cards, home assistance, disabled allowances and all other such allowances and community facilities. Such cutbacks never affect the people at the top of the ladder, it is always the weaker sections of the community who suffer.

I do not know what the position will be with the health boards in the financial state they are in now, but if they have to turn, like some of the county councils all over the country, to borrowing money from the banks to keep the services in operation that will be a very poor day. Some of the county councils have to borrow money at the moment in order to maintain employment.

I hope the Minister will be able to talk to the Government and ask them to provide the additional money to keep the health boards in operation in the same way as they were last year. Nobody can deny that there is a lot of scaremongering going about to the effect that there will be cutbacks here, closures there, and some place else will not be open. People all over are saying it. The Press are also saying it. They cannot all be wrong. If in the middle of the year there is a shortfall in capital and the health boards have to resort to going to the banks, it will be a very bad day for us. I do not believe money should be borrowed unless it is for productive purposes. I do not believe in borrowing money to put the bread and butter on the table. People who do that in their own homes are on the road.

The CEO of the Midland Health Board stated that if that board did not contain their financial spending within the amount of grant they received from the Department the Minister would invoke section 31 of the Health Act. That is a serious position for any board to find themselves in because it will mean they will not be able to borrow money and must remain within the limit. In order to do that, the health boards throughout the country will have to cut back on the services they are providing. The Midland Health Board cannot operate unless they get an additional £400,000 from the Department of Health. I presume the Department have been asked for that money. Perhaps the Minister will be able to let me know if that money has been granted to them.

It is interesting to see this relatively small innocuous Bill which has created quite a furore between the medical profession and the Minister for Health. The Bill merely intends to collect revenue. It is merely to ensure that the direct contributions from those who are obliged to pay for the health services should be increased in line with inflation. That is not even one-fourth of the answer to the problem. Each working person in the country is paying £5 a week without getting anything. This is a tiny drop in the ocean to what is happening. This should be borne in mind by the public at large.

We have got to nail once and for all the myth that the more we pump into the health services the better services we will have. In Britain after more than 20 years they find the waiting lists as long as they were in 1947 and the problems now are as great as if not greater than they were at that time. If you create the money the demand will increase and we are not solving the problem of our health services.

We know there are urgent needs in the health services but these are not being served by the way we are deploying our resources. A sum of £262 million is being spent this year on health services while many people are crying out for assistance towards the cost of a family doctor service; the drugs position is deplorable and a terrible indictment of the Department of Health. There is abominable waste going on and the Department of Health are responsible. When I say this I am not indicting the Minister but the Department who have asked the Minister merely to carry on this tremendously wasteful programme they have. They have never attempted to rationalise or to look at the matter from outside. They are inside and they cannot see the wood for the trees.

The Department of Health continue with each Minister to tell him the way this is to be done. There will have to be changes in the Department of Health. While £262 million is being spent on our health services a large number of people are saying that our health services are far from satisfactory, are inadequate and are not filling our needs. The same old policy is being operated in the Department of Health. When I suggested some time ago that an all-party committee of the Dáil be set up to investigate this terrible extravagance that is going on it was not accepted. I was deluded into thinking that the Minister had approved my suggestion that an all-party committee of the Dáil be set up to investigate the structure of the health boards, how they were functioning and to see if we were getting proper value for money. The Minister says he subscribes to the idea, but that means nothing. I should like the Minister to say in reply to this debate, that he will, in the interests of the public, set up such a committee. There is public disquite at the terrible extravagance that is going on in our health services.

We do not have proper health services. Money is being wasted. A sum of £262 million is no small sum. I have a right to ask on behalf of the people that we get proper value for money and see that the money is going into areas which need it. The problem which has arisen now between the medical profession and the Minister is one which we cannot debate because we do not have figures.

The Minister says there will be no increase in the numbers eligible. The medical organisations on behalf of the medical profession say 300,000 extra people will become eligible for the health services and for the hospitalisation services. I cannot ascertain what is right and what is wrong. No Department can give the answers to this problem. I do not know where the Minister gets his information when he says 85,000 people will become ineligible. I cannot get that information. I cannot find out the number of non-manual insured workers earning below £3,000 a year. I cannot get information about their families. We have an abysmal lack of information in regard to statistics. We are the worst country in Western Europe in regard to statistics. You can spend the whole day going from one Department to another and you will get no information.

It is important to ask the Minister to clarify this. What information has he to suggest that the numbers will not increase? I will explain why I am saying all this. If 300,000 extra people are added to our hospitalisation service, I am telling the Minister and the House that our hospital services will collapse. It is as simple as that. The disadvantaged will suffer. The people who are most in need, the people at the lower end of the ladder, will suffer because they will be relegated to the end of the queue. Instead of waiting for two years for attention to be paid to an eye complaint, they will have to wait four or five years. That is what we are faced with. If the medical organisations are correct in what they say about an extra 300,000 people added to our medical services, then I predict a total collapse of our health services. That is a very serious charge to make.

For the Minister's edification I will explain where those 300,000 will come from. The medical profession say an extra 10 per cent will qualify, and that is 300,000 people. That is what we must bear in mind. That is what we must talk about. At present our hospitals are bursting at the seams. I am tired saying that in this House. Those who try to refute what I am saying, those who say I am exaggerating, should visit the hospitals, not the private hospital which was given £3 million by the State but the other hospitals. They should go and see how bad they are. By normal sanitary standards some of them should be closed. Infection is rife and disease is prevalent. We hear talk about a national hospital plan being on paper but to me that is a myth. Nothing is being done about it. We had this in 1936. We had it in 1966. One Dublin hospital have a site since 1934. They have been awaiting a decision from the planners, awaiting a decision from the Department of Health and waiting for Ministers for Health to make positive decisions to go ahead. If an extra 300,000 people become eligible for our hospital services, our hospitals will not be able to cater for them. They will not be able to cope with this problem.

I will give some details. At present it takes two to two and a half years for inclusion for an operation for hip replacement. Thousands are waiting on this. In the north-west of Ireland, it takes two years for admission to an outpatients' department for an eye examination. It takes two years for admission for a tonsil operation. These are some of the basic facts about our hospital services. A previous Minister for Health denounced me in the Dáil because I said a famous professor said the health services for the coloured in Africa were better than ours. He saw our hospitals and he said the coloured in Africa were treated better. What he meant by that was that the coloured do not get a fair share of the service in southern Africa, but they are getting better attention and better hospital services than we were giving here. He made no bones about this. We must look at the problem and see what is wrong.

I believe the problem is not money. It is the waste and the extravagance and the wrong set of priorities. You can throw in as much money as you like. To me it is like throwing paper into a furnance. It will burn up as fast as you throw it in. The answer is not to throw in the money but find out what is the best thing to do. You say: "Let us rationalise. Let us get proper value for this money." We are not doing that. No Minister has taken on this task. They all say: "Let us call in consultants. Let us employ the American system." It does not call for any expertise to know what is wrong with our services. It has been spelled out over and over again. It is obvious to us all and we must decide what to do about it. That is why I suggested we might set up an all-party committee to examine the whole structure and to see that this £260 million is being properly spent on behalf of the public. I have a right to ask for that. The public are paying for it.

It is important for me to refer to drugs now. We all have a notion that doctors are abusing the whole question of drugs. There are life-saving drugs which are vital to the community. Properly used they can save lives. I should like to refer to the recent tragedy when a child was not seen in time. Without knowing the full facts of the case, I think it is important to dwell on it now to see what we can do to avert further tragedies where a life could be lost. I am not saying that if the doctor had arrived in time that life could have been saved but we must think about this. One life is very precious in our society. If one life is lost accidentally it is up to us to have a proper investigation and to see that this does not happen again.

We are living in an age when everybody wants time off. People are making more demands on doctors. They are going to them more often and with more trivial complaints. A doctor is tired when he has done a lot of work and he wants time off to study and to keep up to date and also for leisure. It seems to me that in the case to which I am referring they had no family doctor. Everybody should have a family doctor who could educate them on health as well as illness. From my information there was no family doctor and they looked up the yellow pages. A doctor who is overburdened is reluctant to take over the case of another doctor.

In a situation like that where people cannot get a doctor and where they think the problem may be serious, we might have the task assigned to one hospital of having a telephone number which would be regularly advertised to the public. This would be open to abuse. As I said about social welfare, it is open to abuse, but you cannot close down the labour exchanges or the Department of Social Welfare because the system is open to abuse. I am suggesting that you could have doctors at the end of a telephone as part of a national public service. When they learned what the case was, and when they heard a doctor was not available within a reasonable time they could undertake the task of contacting the doctor or his locum. If he was not available they would have the right to direct an ambulance to take the case to a hospital. There is a lot of work and extra expense involved but one life is very precious and if we can avert further tragedies such as happened we will be serving a very useful purpose. We must look at this matter because I do not think it will be the only tragedy. I know the Minister is sympathetic to this problem and I would ask him to consider whether this service might be made available. Many people do not know what is an urgent case, when they telephone a doctor they may not give the message correctly. I remember having an answering machine on my telephone. On one occasion a child was sent out to phone and just gave the message that I was to come to Mrs. Smith. When I got the message I had to go through a whole file and it took me hours. A hospital could easily take on the task of a central service; it might be regarded as part of the postgraduate work of doctors. I felt very sorry about the case that was mentioned because I realised it could have been my child. If it had been perhaps I would have gone berserk. Perhaps an antibiotic drug could have saved that child.

There are life-saving drugs and they have relieved the pressure on hospital beds. In the past where there were cases of severe chest and other infections we could not take a chance but now we can prescribe antibiotics. There is a certain feeling of confidence because we know that the antibiotic will hold any secondary infection at bay and it is not necessary to see the person every few hours. There are some magnificent drugs for heart, blood pressure and for kidney trouble. They have revolutionised the treatment, they have made doctors' lives much simpler and have improved the outlook for people.

There are other drugs that are unnecessary and ones we could do without. There is a little too much reliance on tranquillisers and sedatives. I have consistently maintained the view that unbranded drugs not only may be ineffective but may be dangerous. I have seen what happened in dispensaries prior to the introduction of the choice of doctor scheme and I saw literally tons of tablets being destroyed. They were bought in bulk by the combined purchasing section of the Department of Local Government. They came in tins containing 10,000 or 20,000 tablets with a label stuck on the outside. They were unmarked white tablets. The adhesive on the labels was not secure, the labels fell off and the result was that the whole cannister was unmarked. This, of course, was a complete loss.

A company was set up here called Intercontinental Pharmaceuticals. I can name the man concerned; he is in Cyprus at the moment inflicting himself on the poor people there. His name was Sigmund Ziecko. It was not his right name——

I am sure the Deputy will appreciate that names should not be mentioned.

It was not his right name; he had five or six names. The name he used was not the right name, as they found out in Britain. He started to import a drug here and he told everyone he could let them have it at quarter the price. My own mother died because the drug did not work. It was only syrup and there was no antibiotic in it. I did not realise this until I saw a similar case in Britain. In that instance a child died, the pathologist had the drug tested and it was found that it was only ordinary syrup. I questioned the then Minister for Health, the late Donogh O'Malley, and courageously he said that the drugs were bought by the Department but that they had to withdraw many of them. They were not effective and they did not have the right potency; in fact, some of them had nothing at all. I remember that the Dublin Health Authority, despite a warning from the Minister for Health, bought drugs to the value of £28,500 and they had to be discarded. It was a game of conmanship in selling these drugs. They were available at a special price to the health service here. In Britain this man did the same kind of thing. He had powder formed into capsules and he called it ampicillin but it was not that at all. All of the people connected with this case started to sue this man but he formed £100 companies and nothing could be done. There is the danger that in the interests of economy we may be providing inferior type drugs and, secondly, that we may not have enough control over them.

I am open to correction on this, but I think the National Drugs Advisory Board have quality control of certain drugs but I do not know if they can do this with regard to unbranded drugs. We must be careful in this area. Of course there are abuses with regard to drugs. The choice of doctor scheme has been in operation for only three years and it is inevitable that there will be abuses. If there are frequent pleas to doctors to be more discriminating and selective in their use of drugs we will reach a situation where drugs will be used for their proper purpose. We must educate the public not to expect a prescription at the end of every medical consultation and we must dispel the notion that there is a pill for every ailment.

Drugs cost about 3.5 per cent of the health service—certainly not more than 10 per cent—but in comparison with the saving effected by way of easing pressure on hospital beds they are serving a good purpose. If we are more selective and if patients do not ask for drugs for every sickness we can eliminate any waste. However, that is only one small aspect of the cost of the services. We must look at some of the other problems. The greatest costs in hospitals are labour costs. The costs in respect of doctors form the lowest proportion and the costs for nursing personnel are the highest. We must have regard to the fact that we have only so many hospital beds. There is a tremendous demand on them and the waiting lists are so long that I get fed up trying to get a patient into a hospital. I can see the answer all the time. We must remember that the out-patient departments of the hospitals can be streamlined. I have said that over and over again but nobody listens. We must tell the medical and nursing professions and other ancillary bodies that the out-patient departments must be streamlined. We must have X-ray departments working around the clock. It is expensive equipment and to close down such a department at 5 o'clock in the evening is ludicrous. It is unnecessary waste.

If we had the X-ray departments working around the clock we would get proper use of them and reduce considerably the waiting lists for these out-patient departments. We should introduce proper diagnostic centres so that patients would not have to be admitted to hospital for investigation. I am opposed to a person being admitted to a hospital for investigation because there is no more unpleasant or depressing place than a hospital, particularly when a person is sent in for investigation. It should be possible to carry out all the investigations on an out-patient basis, if we were properly rationalised and organised. This is long overdue but the Department of Health are ignoring this important aspect of the matter. We could arrange to have a person X-rayed and blood tests taken in a short time.

I should now like to deal with the questions of appointments to see specialists. I have looked at this on many occasions and wondered what is wrong. I came to the conclusion that one would have to see the problem first. Nobody seems to realise until he comes in contact with the situation what is wrong. Anybody who has had the misfortune to look for an appointment for eye examination finds himself in a terrible predicament and having to wait for months. I have suggested— I have written about this matter on many occasions—that we might take in the opticians. I talked to the ophthalmologists and they say that clinical assistants should be taken in. The clinical assistants they are referring to are doctors who have a diploma in opthalmology but who do not wish to become absolute specialists. They could assist by doing routine examinations of the eyes.

I do not take the word of the medical profession as gospel and I do not hold any brief for the medical profession, and they know that, but we have a precedent for the employment of opticians in our health services. I cannot see why an optician cannot be employed in an out-patient department to check eyes. It is ridiculous to have an eye specialist whose skills should be employed in complicated eye work doing routine testing of the eyes. This is where the expense is being abused. The whole system is wrong. It is wrong to have an eye specialist earning £12,000 a year just testing eyes when an optician could do that.

The Minister may tell me that it cannot be done but I intend to show him that he is wrong because the Minister, as Minister for Social Welfare, is already doing it for social welfare patients. If it can be done for such patients why can it not be done in the health service? It is the most ludicrous thing I have ever heard of. I do not see why the Minister does not call in the opticians tomorrow and make an arrangement with them to work under the supervision of doctors in out-patient departments. If that was done instead of waiting for one year for an appointment in a hospital a patient would only have to wait one week.

The Minister, as Minister for Health, bears a great responsibility. I should like to tell him that a lot of people have gone blind—I say that without intending to cause alarm—as a result of this waiting list. There are certain conditions that if treated in time would result in people keeping their sight. Glaucoma is a dangerous condition and if not attended to in time can cause blindness. Patients have to wait up to two years but in the end it is too late and there is nobody to tell them that it was the cause of the Department of Health because the people do not know otherwise. The blame lies with the Department of Health and I have no hesitation in indicting that Department for not looking at that situation. Is that rationalisation? Does that indicate that we are providing a proper health service? I do not think so and I do not care what the Minister, or his advisers, say. I could not have respect for advisers who do not advise their Minister properly, especially when people go blind.

I said this two years ago but nothing was done. I will be saying it again two years hence unless I force the Minister into doing something about it. Why can we not get such rationalisation in the hospitals so that we can get a higher bed occupancy rate? Does a patient, after an operation for appendicitis, have to stay in the hospital under skilled care and attention for the duration of his stay? Such a patient is out of bed one day after the operation. Why can he not be moved to a hostel attached to the hospital where he can be watched and where he can go to a canteen to get his own food? This would reduce the cost enormously and get beds for those on the waiting list. This is the way we must talk about improving the service when we are talking about £260 million which I say is being wastefully used in this service. It is costing the people a lot of money and they have a right to ask questions. Nurses and doctors are very expensive. I do not think a nurse should be employed to take in a meal to a person who is up and about when that person could be moved to another section of the hospital.

I said this five or six years ago but nothing was done about it. The Minister has boasted that he is giving more to the health services than was ever given but to me that is an indictment of a Minister. It means that there is more expense, more waste and more inefficiency. It would be possible to have a proper health service without that amount of money. Were I Minister I would not boast that I was giving more of the GNP to the health services. I would be afraid to say that.

I have been a member of a health board for 25 years and I can tell the Deputy that you cannot get these people. He is talking nonsense.

The Deputy will get the opportunity of making his own contribution later.

I will make my contribution but I cannot listen to this.

Unless we look at this in a rational manner we will not improve the service. We could get in 2,000 dentists but does that solve our problem? We can have all the teeth extracted and everything done but that is not solving our problem. We must look at each facet of the problem to see what is wrong. The officials of the Department of Health must think that I am paranoiac about them because I attack the Department at every opportunity. I wrote to the Minister for Health in 1959 having seen patients, while I was working as a doctor in a hospital, delayed and kept in hospitals because the consultant did not come in. I thought it was terribly unfair to these patients. I wrote to the Minister for Health, Mr. McEntee, about this, and put forward a suggestion to him. I said how we could reduce the number of days a patient spends in hospital. No doubt, the Minister never saw the letter. The adviser in the Department wrote back and said: "The Minister has asked me to reply to your letter and to tell you that he has no function in the matter." That is typical. That was the Department of Health to me and from then on I lost respect for the Department of Health. I could never have respect for the Department unless there are major changes made in it. The Minister knows that I feel that way about it. I have seen several mistakes made by the Department over and over again. I have seen the cover up about things. I could not say enough against that Department.

Have we seen any evidence of proper output budgeting? Have we seen any testing and monitoring of different programmes coming from that Department? We have not. We have seen nothing. They just say that they need more money but they never say why. That is the question we have to ask— why?

We are forced into this situation at the moment. I condemn the situation at the moment because these cutbacks did not come from the Department of Health in an effort to rationalise. That is different. If organised cutbacks had come from the Department of Health I would be the first to stand up and pay tribute to the Department. If the Department of Health had said: "We are doing this because—" I would pay tribute to them. This was the problem of the health boards. The cutbacks were crisis measures imposed by a Minister for Finance who said: "There is not any left". They were not planned cut-backs. There was no adequate notice given of them. If they had stemmed from that motive I would have seen merit in them and would have been the first to praise the Department. They came as crisis measures. They cut back everything. That is what caused the trouble. There was no planned action. I do not see any evidence of planning within that Department under this Administration. McKinsey and Company thought they might structure it on the lines of the American——

McKinsey is the cause of all our trouble.

That is what I am saying. I am glad we agree on it.

Who took their advice? It was not the present Minister.

I am sorry to be so hard on the Minister for Health. He is a courageous Minister. Maybe McKinsey was not the infallible.

McKinsey is the man to attack.

I have not seen any attempt to unscramble the scrambled egg. I would have thought we might have seen some rational approach to it, some attempt made to look at it and say: "Maybe they are not going right. Maybe they are spending too much money. Maybe they are not achieving the purpose for which they were set up". I see no major policy statement from the Department of Health. I have seen no proper budgetary programme from the Department of Health. Maybe I have seen evidence of conversion to rationing health services from Michael B. Cooper's book in Britain but I do not see any policy objectives. The day I see that is the day I will be paying tribute to the Department of Health.

I have been preaching for a long time that we should pay more attention to health education. What do we see in health education? We see a pretence at educating the public about health, a few advertisements on television. Do we see proper courses of instruction in schools about the functions of the body, about the need for health, about the need for exercise, the need for proper recreation? We do not see anything like that. Do we see proper liaison with the Department of Education about including such courses on the curriculum? Is the Minister aware that there is a very high percentage of people who do not even know the normal physiological functions of the body? This is what we should have in health education, not just an advertisement about drink, tobacco and drugs. That is one facet. When I get up and talk about health education they say: "That is it. We will do that".

There is a fair amount of money in the Estimate this year for health education.

It is a drop in the ocean compared with the £262 million being spent on health. It is very small. That money could have been quadrupled to produce what we are aiming at, that is, teaching people to pay more attention to health so that they will not have to avail of drugs and doctors' services, so that they will be able to assess their problems, so that we will be talking in terms of a healthy nation instead of an illness orientated nation, which is now the policy that is so prevalent. I would not be proud of the fact that we throw so much money or such a percentage of the GNP into the service. I would prefer to talk about what we spend on educating the people about health. I may be perverse. I may be too unorthodox to meet the norms of our society but I believe we should talk about health education on a vast scale. not just in the area of drugs and drink and tobacco. It is more than that.

Of course, it is.

I do not see evidence of it, with due respect to the Minister. I want to see evidence. When I first approached the Health Education Bureau——

We took your advice.

You did take my advice but the Department did not even know what I was talking about.

That is cod.

It was too tiny a thing. They would need to go wider and talk about this in a proper way. I am sorry but I shall keep arguing and talking until I get it done. It is in the best interests of the people. I will make an enemy of the Minister but I prefer to speak out openly.

Join the club.

I feel justified in doing it.

Come to your own profession and tell us about that.

Yes, I will come to that. Perhaps I will mention some problems in our own profession, for whom I hold no brief. We have to look at the whole question. I said this a long time ago. First we have to decide who is to decide the priorities. Is it the doctors? We have so much money and we have to spend it to the best advantage. Who is going to make the decision as to where that money is going to be spent? Who will decide the priorities? A replacement operation may make a person ambulatory but the question of age comes into it. I mentioned in the Dáil a year ago the case of an 80-year-old man who had a hip replacement operation. To me that was an abominal waste of money because of the fact that he was 80 years of age. The chances of his wanting to run in the Olympics were remote. I wondered why we should spend the money involved on an 80-year-old person. I do not want to deprive anyone of anything. The risks involved in a major operation on a man of that age were too great. He survived the operation but he was never mobile again. That is what I want to say. Therefore, I must ask who will make the decision and I have asked this before. Are we to decide that an operation which may cost £1,000 and involve £300 a week in maintenance for that person is the best thing to do or are there greater priorities? Is it better to think of children who may need vital operations? These are problems that will face any Minister for Health. I move the adjournment of the debate.

Debate adjourned.
The Dáil adjourned at 8.30 p.m. until 10.30 a.m. on Thursday, 25th March, 1976.