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Dáil Éireann debate -
Tuesday, 30 Mar 1976

Vol. 289 No. 4

Health Contributions (Amendment) Bill, 1976: Second Stage (Resumed).

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

I think—and I adverted to this in a superficial way the last day—the present difference of opinion or, as I would rather say, difference of view about the numbers who will be affected by the extension of eligibility for free hospitalisation is something which should be clarified immediately by the Minister for Health, because the Minister says that unless he takes action immediately an estimated 85,000 workers who are at present eligible may become ineligible by the end of the year, whereas the medical organisations say that extension of the limit of eligibility will mean an extra 10 per cent of the population becoming eligible, that is, an extra 300,000 people. This raises the whole question of the adequacy of the hospital services to cope with this increasing number, if what the medical organisations say is true.

As regards the grievance of the doctors involved, the Minister is being blamed, rightly or wrongly—I cannot say—for making decisions without adequate consultation and agreement with them. Their argument is that, as a staunch trade unionist, the Minister should appreciate the need for such consultation and agreement with those working the service. This is one sore point with them, and understandably so. I would ask the Minister to examine urgently the whole question of hospitalisation and out-patient services and find out the cause of the present long waiting lists. If he could do this, it would be of inestimable benefit because he might be able to seek out areas of priority where these waiting lists could be reduced considerably. There are vital areas where the waiting lists is abominably long, for example, for eye examinations, for essential operations, in many cases operations which would restore people to full-time work and normal living within their community. This would call for extra work in the Department of Health, and this is where the big bottleneck occurs. I would ask the Minister to examine these waiting lists because this is one aspect that is getting rapidly out of hand.

The Minister might be well advised to pay more attention to primary health care and to try to case off the demand for hospital services, especially where investigation or treatment for minor ailments arises. However, I would feel very concerned if the Minister were to change the present system of contribution towards the cost of drugs. If the Minister increases the limit at which people become ineligible, as is suggested and as the Minister stated in one of his speeches, this would be a retrograde step, because people would too readily opt for hospitalisation in preference to being treated at home, and this is one area where it might be false economy.

Considering that a greater number of people are becoming ineligible for medical cards, I begin to wonder if the guidelines have not been extended sufficiently in line with the rapid rise in inflation. Evidence of this is forthcoming in the number of people who are now being refused renewal of their medical cards. This, again, is an area which needs priority.

In view of the inadequate facilities in our hospitals, I would ask the Minister to make a declaration as to what he proposes to do about free hospitalisation. Is it a firm commitment on his part to proceed with this? Among those working the service there is a fear that he is trying to bring in free hospitalisation by stealth and this is causing considerable disquiet. He should make a firm declaration on whether he proposes to extend the free hospitalisation to all. It is incumbent on him to clarify this point. He should state what is happening to the practically moribund review body which has been in operation since August, 1974 and which is looking into the methods of payments to those operating the service. There was talk about the members of the review body going to Scotland, Canada and Europe to examine methods there. That body should have made their report by now and the Minister should call for an interim report. As the review body was set up by the Minister, he should ask for and receive an account of their activities to date. This is vital.

People operating the hospital service at present are very frustrated by the appalling conditions under which they work. The Minister should spell out the time table for his national hospital plan. At the moment there is a growing uncertainty in the hospitals and there is talk of bringing the service to a halt in protest at the Minister's procrastination. If this were to happen, it would create a chaotic situation. It is important that we restore confidence to the people working the service and give them hope that new hospitals will be provided. The publication of the plan without the time table is a serious matter which calls for positive action. If the Minister were to publish the plan and the time table, he would be sure of the co-operation of the profession and there would not be confrontations which have been occurring since he took office. More consultation and agreement with the medical people would ensure harmonious relations between the Minister and the profession and this is very important. It has been said that relations between the Minister and the profession have never been worse since Mr. MacEntee was Minister for Health. The Minister, as a staunch trade unionist, should appreciate the value of prior consultations with affected interests.

The financing of the health services should be looked into. The Irish Independent brought to light that the Minister mentioned in December, 1974, that a review of the methods of financing the health services was being undertaken. What has happened since? Apparently, nothing has happened to indicate if the Department are still working on this. Again, it is incumbent on the Minister to tell us if any action has taken place in this field or are the Department leaving matters in abeyance? I hope to see some major changes in the Department of Health because of programme budgeting, output budgeting. I expect there will be some effort at rationalisation within the Department This is necessary if we are to have a proper health service.

It is also incumbent on the Minister to spell out exactly what he means when he says that 85,000 people will become ineligible. How did he arrive at this figure? I have been unable to ascertain who would and who would not be eligible under the proposed extension. It is important that he spell out where he got the figure of 85,000. It would be proper to extend the health service if the hospitals were capable of coping with the extended service. If the service were extended at present, we might end up by making the situation for the most disadvantaged members of our community more difficult. We might find that those at the end of the queue for admission or investigation will be relegated further down the list. This is a real possibility which we should bear in mind. It would be disastrous if, in our efforts to extend the hospitalisation scheme, we were to make the most disadvantaged members of the community worse off. That is not the purpose for which we would be improving our health services and this is what we would have to spell out. We would want assurances that those people will not be adversely affected by any proposal put forward by the Minister.

The Minister has an opportunity here to spell out his thoughts on the health services, what he proposes to do, whether he intends to meander along increasing the health contributions to cope with inflationary trends or if he has active proposals for helping those in need. We should know which the Minister considers more important, primary health care or free hospitalisation. In Britain they realise that primary health care is the pivot on which the health service revolves. They realise that they made mistakes when they planned their major hospital schemes and an extension of the hospital services without looking at the health needs of the nation. I would like to hear the Minister's priorities in this regard. Then we will be in a better position to know in what direction the Department are going.

In his reply, would the Minister state unequivocally if it is his intention to set up an all-party committee of the Dáil to carry out a cost benefit analysis of the health boards? If the Minister made a statement to that effect, it would be a great help, especially at present when there appear to be runaway inflationary trends in expenditure by the health boards.

I should like to make a brief contribution to the debate on this Bill which proposes to increase the contribution for insured persons up to 33p per week and the rate payable by other persons up to a limit of £15 per annum. It is well known that this is another budgetary effort on the part of the Government, the second supplementary budget we have had in the past few weeks, counting the recent Social Welfare Bill, which increased substantially social welfare contributions.

We must ask ourselves whether these people are getting value for their money having regard to entitlement to eligibility, particularly those at marginal levels. Throughout the country there is grave dissatisfaction with the administration of the health services, particularly the cut back in improvements which has been taking place in regard to the operation of the services, the provision of facilities for the services, the appointment of experts and the provision of accommodation. The people are dissatisfied because of the proposal to cut back the services at least to the 1975 level and also because of the obvious mismanagement of the financial affairs of the country by the Government. People had become accustomed to a rate of progress during the last decade and are now gravely dissatisfied, particularly with the health services.

Take, for example, the general medical service register, the provision of GP services for the least well-off sections of the community. It is well known that a serious effort is being made by health boards to cut down substantially on the number of persons eligible. In South Kerry I come across this daily, week after week. There is a feeling throughout the length and breadth of the country that there is to be a severe cut back in regard to the register. It is being done in different ways. First of all in some health board areas and assistance districts the instruction is that people who recommend persons for eligibility should stick rigidly to the guide scales laid down by the Minister and members of health boards are being told that. On the other hand, applicants for the general medical services are being told in no uncertain manner that things are tougher now and that many applicants for renewal of medical cards will be dealt with more severely.

It is a real heartbreak for old age pensioners, people who have served their country well through the years, to be told they will no longer be automatically eligible for registration in the GMS register because they are in receipt of non-contributory old age pensions or widows' pensions. It is very hard to explain to such people the present serious economic position because they have experienced substantial improvements in their position during the past decade and overnight they have seen a serious deterioration in so far as eligibility is concerned. This is serious not only from the point of view of welfare but also of the morale of the people and the confidence of their children in the future of the country.

I have received numerous complaints from people in regard to the scheme of limited eligibility and I have written time and again to the Revenue Commissioners, to the Department of Health and the health boards. Many of those people enclosed cheques or postal orders for £12 and three months afterwards the money was returned with the instruction that they complete application forms and that then the applications would be considered seriously. They were also told months afterwards they would be informed later of weather they were eligible. There seems to be a serious lack of urgency on the part of the officials who operate this scheme and a lack of communication between them and those who want to participate in the scheme. This is a genuine complaint and it should be taken up by the Minister with the health boards, with his officials and in particular with the Revenue Commissioners.

There is grave dissatisfaction also in relation to many other schemes being operated by the health boards, again concerning eligibility for the GMS register. I understand that the Minister stated today he is not responsible for the guide scales laid down by the CEOs. Members of health boards state, however, that the CEOs quote the guide scales laid down by the Minister to them in determining eligibility for registration. Is the Minister serious in saying that a married man with an income of £29 a week or more is now entitled to a medical card?

If the Minister states that he does not agree with me then he should issue instructions to the CEOs to increase the limit as regards the guide scale for eligibility. It is a well-known fact that a married man with an income of £28.50 or more, which is the actual limit as per the guide scale, cannot possibly provide the general practitioner service or drugs and medicine for himself and spouse. The allowance per child is only in the region of £2.65 to £2.75 per week. It is quite obvious that under the guide scale at present, whether it was laid down by the Minister for Health, by his Department, or by a meeting of the CEOs themselves, this limit is completely unjustified, unreliable and is grossly inadequate as regards present day standards.

I should like the Minister to state clearly who has laid down the scales. Quite recently the Southern Health Board, on the recommendation and instructions of the CEO, stated:

The above guidelines are hereby amended by adding the words "at the maximum rate" after the following in paragraph (a) "old age (non-contributory) pensions, widows' (non-contributory) pensions and orphans' (non-contributory) pensions".

In other words, persons in receipt of old age and widows' and orphans' non-contributory pensions at the maximum rate are no longer automatically entitled to medical cards. As an explanation, the CEO stated:

It has been the practice for a number of years to grant medical cards automatically to persons who are recipients of non-contributory old age, widows' and orphans' pensions. It has come to notice that a significant number of persons in receipt of such pensions at reduced rates have incomes which are much in excess of those which would normally qualify them for medical cards. The automatic granting of medical cards to pensioners with such income has given rise to anomalies. Accordingly, it has now been arranged to discontinue the automatic granting of medical cards to them and to consider their applications on their individual merits within the revised guidelines. Medical cards will as heretofore be granted automatically to those who are in receipt of pensions at the maximum rate.

The fact that persons, whether they are in receipt of pensions at the maximum rate or not, no longer qualify for medical cards is a serious set back to the operation of the health services. The operation of the transport scheme to clinics has been grossly mishandled by the health boards on what appears to be instructions from the Department of Health. Up to mid-January, when the bubble really burst as far as the finances of the Government are concerned, the vast majority of medical card holders and their dependants were entitled to transport to clinics and hospitals. Since then, and particularly since the 1st February, it is a well-known fact that these people, with the exception of ambulance cases, have to provide their own transport to clinics and hospitals. The position might not be so bad in relation to cities and built-up areas, but when it comes to the outlying areas and the remoter areas in the west and the south-west, this cutting back in the transport service means not alone a serious blow but could mean the difference between life and death in many cases.

As late as last night I had a case of a person from west Kerry who told me she was called to a clinic in Cork. She went to Cork and was brought back to Killarney by ambulance and had to make her own way back at least 50 miles west of Killarney without being told by the health board as to how she could get there or what she was to do. Subsequently she received a letter from the Southern Health Board informing her that, as and from 13th February, the transport scheme for medical card holders had been discontinued in the Southern Health Board area and that therefore she was not entitled to a refund of the car fare from Killarney to a distance 50 miles west of Killarney town. This is typical of the many cases which public representatives have to deal with at present. It is very hard to explain to these people that the country cannot afford to pay for transport to and from clinics and hospitals and cannot afford to pay their transport home when they are dumped from an ambulance 50 miles from their homes. This is the reality of the situation.

If the Minister wishes I will send him this letter from this woman and the letter she received from the Southern Health Board during the past week. I would not mind if this was an isolated case, but I know well that it is one of a thousand cases. This is a serious national situation and it should be investigated by this House. There is a very serious development recently in relation to all that has been said and done in connection with the curtailment of the health services. The message has been well and truly received by the officials of the local health boards that they should not consider representations from public representatives. At a meeting of the Southern Health Board some time ago members were told by the CEO and his programme managers in no uncertain manner that very little notice, if any, would be taken of their representations and that the representations would be treated as a waste of time.

Hear, hear.

If this is the manner in which the officials of health boards are treating representations made by responsible elected representatives it is very serious as far as democracy, democratic elections and our institutions are concerned. I will not stand for any of this bluff. I have instructed as many members of the Southern Health Board as I know to ask the CEO to come out into the open on this matter. I ask the Minister to tell all the CEOs that they should take representations from public representatives fully into account when considering eligibility of applicants for various services. Officials at all levels in the operation of the health services may not be fully aware of peculiar, difficult and special circumstances which appertain to individual applications. It is the duty and responsibility of the elected public representative to point out these special circumstances to the officials of the health boards, as indeed it is their duty to do so in relation to applications for various other services. The officials of the health boards should, in the same way as officials of other bodies and departments, including State and local authorities, take into consideration representations made by elected public representatives.

This is a serious matter. If the CEOs and programme managers of the health boards are going to insist on these tactics then there will be at least 100 questions each day here down to the Minister for Health seeking explanations why individuals did not qualify for various services. It would mean that night after night when the Dáil is sitting, we would have adjournment debates about matters which are really personal affairs and which we public representatives do not want to bring out, but which, in the interests of justice, fair play and democracy, we must.

We in Fianna Fáil believe that there should be a greater movement towards the community care service. It should be the policy of any Government now and in the future to provide more services at a community level outside of the hospitals for people in need. It should be the policy as far as possible to treat and maintain those who are suffering and require treatment within the environment of their own homes. This will entail the employment of more public health nurses and trained personnel. It will entail more community effort, which I believe is there, provided it gets guidance and encouragement from the Government. It requires a greater awareness among the youth of what can be done to provide care and assistance for those who are suffering, and particularly for the aged. I believe the youth today are quite willing and able and only anxious to provide these services on their own initiative, provided encouragement is given by the Government. Of course, it means that very likely more medical personnel must be made available, but in the longer term it will mean that fewer people in the category that I have mentioned would require prolonged hospital treatment.

Unfortunately at the moment finances are not available, due to the gross mismanagement of the economy, for the employment of more trained personnel and even for the education programmes which are vital for such an effort. More should and could be done and more money should be provided this year for improving the lot of the physically and mentally handicapped. During the latter part of 1975, the Southern Health Board maintained and set out as their programme for 1976 that they would take over certain accommodation throughout the health board area to provide places for retraining and assisting physically and mentally handicapped persons, particularly young persons. Unfortunately, their efforts and intentions were completely negative because the health boards, and particularly the Southern Health Board, were told by the Minister to cut back on their budget by up to £1 million this year. In the Killarney area alone there was a proposal to acquire a certain property to provide training facilities for physically and mentally retarded young persons, but this scheme had to be stopped completely by the Southern Health Board because the Government told them not to provide the money.

I have received numerous complaints regarding pyschiatric institutions which are maintained solely for the treatment of adult persons, that there are in these institutions young persons between the ages of 12 and 14. I know of a number of cases where persons in this age group were transferred from homes for mentally handicapped children into psychiatric institutions. Which were erected and maintained solely for the purpose of looking after adults who are mentally disturbed. It is a very sad reflection on the Administration that in this year such a situation should be allowed to come about. I was very sad when I heard these things were happening in various psychiatric institutions.

This Bill is really no more than another supplementary budget, the third or fourth brought here by the present Government since the disastrous budget of 28th January. I believe the Bill will do nothing whatever to improve our health services, that it will do no more than bring more money into the Exchequer which is crying out for more and more, due again to what I would describe as mismanagement of our finances, bad economic tactics by the Government and lack of any fiscal policy, lack of proper priorities and lack of any real interest by the present Government in the promotion and improvement of our health services. If the Government had any real interest in the promotion and improvement of health services the health boards would certainly never have got the instructions they did get when the bubble burst in the Department of Finance in mid-January.

I speak on this Bill to protest in the strongest possible way at the attitude of the Department of Health in hitting the weakest section of the community by their financial cutback. The weakest of the weakest section are the poor, retarded children coming in from rural areas, children who are now deprived of their only chance and opportunity of getting education and some enlightenment. It reminds me very much of the action of one of the Coalition Governments in taking a shilling off the old age pension. Obviously, they considered that the wealthiest section of the community were the old age pensioners and they took off one shilling. Now, the first people to suffer from the financial "whiz-kiddery" of the Coalition Government are the sick, the aged and the deprived. How can any Government worthy of the name condone such action? How can any so-called "just society" member of that Government see any justice in that kind of action? The socialists in the Government have been shown up as the type of hypocrites that we always believed they were.

The first action of this Government in trying to bring the economy to heel is to deprive the least well-off members of the community of their basic civil rights. I have letters here, and I have sent others to the Southern Health Board and to the Department, about the poor children that have been deprived of transport from rural areas into St. Paul's School, Montenotte, Cork. Do I have to come into this House again as I did some weeks ago when those who were on kidney unit machines were deprived of transport, which in their case was necessary to save their lives because if these people were not on the machine three days a week they would be dead? Yet, an instruction went to the local assistance officers that those people were not entitled to the transport services of the health boards. Unfortunately, it required me to come to the Dáil and expose, by way of special question, the injustice that was being done. It was very quickly rectified then when the Government realised the adverse publicity it generated.

I cannot see why in an area like that of the Southern Health Board, where a capital budget of £40 million is involved and where £20 million goes on administration, some people say there are abuses of the transport system. Yet, the total cost of the transport system for Cork and Kerry is £250,000. Surely if we pay £20 million to administrators it should be their duty to ensure that there are no abuses of the system. A meagre £250,000 is all that is involved. Surely the Government in their wisdom could have taken a better-off or more resilient section of the community than the sick, the aged and the poor to attack. Or have they taken leave of their collective senses and are cutting indiscriminately across pages and pages of figures submitted from the Department of Finance? As a public representative I cannot stand idly by and not protest in the strongest terms against this type of action. It was true for Solzhenitsyn when he said that socialism is anti-Christian. It is anti-basic charity which is all that is involved here. Even at this late hour I would appeal to the Minister for Health to restore to those people their basic civil rights because this is their only chance to get some form of education and enlightenment. It is all very well for the Minister for Posts and Telegraphs to talk to some group about contraception. This will not cost the State any money but we did not hear him talk of the injustices being perpetrated by the Government on our people in this part of the country. He takes no responsibility in this regard.

It is my sincere hope that the Minister for Health will have a rethink on the action he proposes. The money involved is very little while the services being provided are great. It is difficult to understand any politician or groups of politicians using the financial axe in the first place on the poorer sections of the community. I had expected more from the Minister than a cutting back in so far as the aged, the mentally handicapped and the retarded are concerned. We all know that there is a shortage of money but the cutbacks should not begin in the field of health. Proof of what I am saying is contained in a letter which was sent from the matron of a voluntary hospital to the staff informing them that substantial cutbacks have occurred in the funds allocated for the current year, that the hospital is now short of money and that in order to avoid serious problems later in the year which might involve considerable reductions in terms of services to patients, in staff redundancies or a refusal by the bank to honour the hospital's cheques, it is necessary to achieve the maximum saving and increased income where possible.

It must be the greatest possible indictment of any government that they begin their cutbacks by depriving the weak and the aged. In some hospitals there has been a drastic reduction in the amount of food supplied to patients. In some instances cornflakes have been removed from the breakfast menu and there are to be either simpler desserts at lunch or none at all. Also, there is a cutting down in the serving of soft drinks with meals.

Perhaps the reason for cutting down on the cornflakes is a dislike of the multi-nationals.

There is to be a discontinuance, too, of the provision of newspapers while outings to the cinema or theatre have been reduced considerably. There is general disregard for the welfare of the patients. This is a callous attitude. If cuts were necessary they should not have been effected in the Department of Health. One would have throught that proper and adequate diets were an essential element of a patient's recovery, whether his illness was physical or mental. Cutting back in this area must be one of the most false forms of economy possible.

I have information to the effect that in some hospitals there is a considerable reduction in heating while in others heating has been eliminated altogether. I should like to hear from the Minister in this regard. I am surprised that the Minister should have allowed this situation to develop. One would have expected it from some of his colleagues but not from him as I always considered him as being a man who was aware of the needs and the rights of the sick. One can only hope that even at this late stage he will have a change of heart in regard to these cutbacks.

I have letters from constituents which are pathetic. These letters relate to the transport of retarded children. I appeal to the Minister to restore this service. In one small area, Skibbereen, there are eight families involved. Economies in this field are penal.

It is time, too, that the Minister took into account the rights of patients and that a charter to this effect be given to everybody on admission to hospital. There should be the right of a patient to full information, to dignity while detained in hospital and the right not to suffer unduly. How many patients can we think of who have left hospital unaware of what was found wrong with them or the type of treatment they received? In a charter of the type I have in mind all this information should be included. Patients should be told, too, why they are given certain types of drugs, the effects which those drugs may have on them later and also what are the consequences if they do not take those drugs. I know that in Europe at the moment France is probably the only country that has this charter of the rights of citizens. I urge the Minister to consider introducing a charter like that here.

I spoke about the right to dignity in hospital. How many times have we seen patients with groups of students around them, poking at them, looking at them and generally causing what I consider a lot of indignity to the patients concerned? Has the consent of those patients ever been asked for before those examinations are started? We have a very fundamental duty to protect the dignity of the patient in hospital. I suppose the position of a nurse or doctor could be described as a vocation. We have great people involved in our hospitals throughout the country. However, the rights of patients need to be spelled out from the top. Patients should be aware of what their rights are. They should demand those rights, because we are all paying heavily for hospital services.

It is very important that we attack the chronic alcoholism problem we have in the country. I am disappointed that in the Cork Regional Hospital there is not a special wing devoted to the care of alcoholics. Alcoholism is a far greater problem than is realised. All the statistics available to us give us reason for concern. We have not even dealt with the tip of the iceberg. As a community we are doing very little to help the alcoholic. If the Minister has any influence at all I urge him to try to establish an alcoholic wing in the new Cork Regional Hospital. Alcoholics are being exploited by a lot of people. They are not getting the treatment they are entitled to. I am speaking for my own area of Cork. It is not right that an alcoholic should find himself in a mental hospital recovering from his bout of drink. This does not help the recovery of the alcoholic. We should have special units, with specialists in the field of alcoholism, devoted to helping the alcoholic. We have been very remiss in relation to our treatment of alcoholics. The Minister for Health must also be aware of this. I hope he is taking action on this matter and that he will try to ensure that this dreadful disease gets the proper treatment and that we will have a higher rate of recovery from alcoholism than we have. Despite the great work of many voluntary organisations, including Alcoholics Anonymous, which must be the most divinely inspired organisation on earth, we are still not giving the proper treatment for the recovery of alcoholics.

I should like to take this opportunity of paying tribute to the psychiatric nurses in Cork. An attack was made on them within the past couple of months by a Sinn Féin member of Cork County Council. He alleged all sorts of brutality and cruelty to patients, which was completely disproved. Nevertheless the allegations got the headlines and caused quite a lot of disturbances among the people who had relations in Our Lady's Hospital, Cork. I know of no other body of people so devoted and dedicated to their work than psychiatric nurses. I do not say this for any political reason because I would not have one psychiatric nurse living in my constituency. I say it as one who grew up in the grounds of a mental hospital, where my father and mother worked. I am aware of the tremendous charity which exists among all those nurses. I deplore any attack by any public representative on those great people. We could not run our mental hospitals without them.

I said at the outset I would not delay very long because I know there are other speakers anxious to get in. However, I feel very strongly about the issues I have raised with the Minister. I ask him again, in relation to the transport of retarded children, that we do not go back again to the dark ages and to the era when such a poor child was locked away in a room for his or her life. I know the Minister would not like to be associated with such a move. He can make a very positive contribution to the treatment of retarded children by restoring the transport system for them.

Like previous speakers I do not intend to delay the House very long on this matter. I welcome the opportunity to express my views on the Bill. The Minister for Health is primarily responsible for the health of all the nation and particularly for that of each individual. I am afraid, seeing that financial pressure is very heavy on him at the moment, that he might be forced to adopt a compromising stance. I sincerely hope he will be able to resist any pressures in this direction. This Bill before us today is a revenue collection Bill. The Minister hopes that £10.2 million will be collected this year from this source.

Generally speaking, people qualify for health services through different channels. The Health Act, 1970, provided for free inpatient and outpatient treatment for all persons who had full or limited eligibility either by way of national health insurance or, in the case of a farmer, where his total rateable valuation did not exceed £60, or in the case of other persons where their income did not exceed £1,600 a year. Then we had the Health Contribution Act, 1971, which is being amended by way of subscriptions, and which caters for people in the middle income group who are obliged to pay a contribution of £12 per year. This becomes £15 per year on 1st April, 1976.

If we examine how this contribution is collected we see difficulties which, unfortunately, come to light only when it is too late for some people. I hope to develop that point later on. In the case of an insured person, the contribution is deducted directly from the wages. In the case of a farmer, the contribution is collected by the various health boards. In the case of other persons, it is paid directly to the Revenue Commissioners. Even though some difficulties may accrue to people who are paying this £12, which will now become £15 and which is an obligatory contribution, a receipt from the Revenue Commissioners does not make them eligible. That is a point I should like to develop a little further. Perhaps the Minister will come back to it himself.

Many people are under the impression that when their £12 has been accepted by the Revenue Commissioners they are eligible for health services. This is not so. A person might pay his contribution to the Revenue Commissioners this year, next year and a third year, in his own knowledge that he is entitled to benefit. Some people in this category find that, before they leave hospital, they are presented with a bill and told they are not eligible because their income has gone above the statutory £1,600. It is the Minister's duty to point out to everybody that the onus is on them to check from time to time to see if they are eligible. I cannot blame people who find themselves in this position. They sincerely believe that the payment to and receipt from the Revenue Commissioners are sufficient. A great deal of clarification and publicity would need to be given to this.

It is small consolation that, after a period of illness in a hospital, and after they have been presented with a bill, the Revenue Commissioners return the £12 or the £15 as it will now be. This is not sufficient. It is the Minister's function to look after the health of each individual and to make people aware of their entitlements and the different procedures. I hope I have made the position reasonably clear. I hope the Minister will spell out whether what I believe to be the position is the true position. It is quite involved and difficult to follow.

The Minister is acting in the role of a revenue collector. In the early days after he came into power he had aspirations about making free hospitalisation available to everybody. Of course, this is a very simplistic notion. When one becomes aware of the various constraints involved, one realises that this is a dream which is not attainable at the moment.

People have become very confused with regard to VHI payments. For a long time they did not know whether they should continue to make their VHI payments. Some cancelled them because they felt they were entitled to this benefit. Later they discovered they had not got medical cover. The VHI scheme is a wonderful scheme. Most people who avail of it, and who contribute to this form of health insurance, find that it meets their needs. At the moment the VHI are conducting a publicity campaign indicating to subscribers that, because of increased costs and so on, they may not have sufficient maintenance and treatment units. It would be no harm if the Minister indicated that to everybody because it is his responsibility to look after the health of all and this extends to seeing people have adequate cover.

It is the Minister's desire to make more and more people eligible for the health services. It is one thing to be made eligible for the services but it is entirely different to be able to avail of them. People simply become eligible to join the queue. The queue, which is ever-lengthening, could be compared to the dole queues which unfortunately we see at the moment. Those are visible queues. Many people who are eligible for the health services take their place in a line which is invisible but which stretches on and on. In the case of dental treatment, the delays seem to be exceedingly great. We have not got sufficient personnel to handle the applicants.

It is most regrettable to find people waiting for essential treatment. I know that in our county the dental surgeon and his staff do their utmost but if the ratio is so weighted against him and his staff how can he come to grips with the problem? He presented us with an up-to-date report of the dental services in the county and it was horrifying to see the extent of the problem. The Minister indicated he was going to do something about the matter, but I do not know if he took any action.

In the area of eye treatment, there seems to be a long time between the date of application for treatment and the provision of spectacles. Perhaps the Minister would investigate this matter? The mail of public representatives consists of a considerable amount of correspondence from parents whose children are still awaiting the provision of spectacles. During all this time the children attend school. It is one thing for a parent not to be aware that the child requires glasses but it is quite another thing to know the child has been examined, that glasses have been recommended but that they have not been provided. There is certainly an element of Hobson's choice in such a situation. When people are told they need glasses or other aids they should be made available with the least possible delay.

Will the Minister tell the House what his Department are doing with regard to those invisible queues, where people are awaiting services? In the Estimate the Minister referred to the importance of dental treatment but I do not think there has been any improvement in the situation.

In this Bill it will be obligatory for certain people to pay £15 per year as from 1st April in order to be eligible for health treatment. Regrettably, I think it is a matter of joining the never-ending queues of people who already are waiting too long for services. I hope the Minister will refer to one or two of the points I made. Perhaps he will clarify the position of people who pay the contribution directly to the Revenue Commissioners, who obtain the certificate but who find out too late that as their income has changed they will be faced with a hospital bill and a refund of the £12 or £15.

Perhaps the Minister could arrange that the certificate would have a life span of 12 months as from the date of issue and that irrespective of whether the person's income changed in that period he would be covered. In this Bill the Minister appears to have taken on the role of revenue collector. He hopes to obtain £10.2 million in the present year from this source. He should remember that his primary duty is towards the health of the nation. He should be able to overcome the financial situation and to put it into a secondary place.

Any question of health is of such universal concern that all of us in the House are urged to make contributions in the hope that the present dilemma may be solved. I have always considered that the cost of the health services can be the cause of aggravating the illness of a patient or of the relatives. For instance, where a wife has to go to hospital she is well aware of the many medical and hospital expenses involved and quite often this retards her recovery. When a person is ill he or she needs all the help that can be given. According to a Chinese philosopher, a person should pay his doctor while he is well and not pay him when he is ill. As in the case with much of the Chinese outlook, there is a lot of sense in that.

There is much talk in medical circles today about the need for economy and the Minister must study what it means in this context. If we are to deal with the matter mentioned in documents before us we may save a few pounds but in terms of human suffering or even of death we will not achieve an economy. It is the duty of the Government, through the Minister for Health, to frame health services so that those who are most in need will get all the help they require. I regard this Bill as a stop-gap measure. Some day we will be forced to examine the health services and consider how they may best serve the nation.

The cost of hospitalisation today is frightening when the figures are studied. At the moment a private room in a city hospital costs about £100 per week. It may be said that people who can pay such an amount do not need any help, and perhaps that is the case, but we must remember that by electing to take private rooms they are relieving the strain on public wards. In this way they are making more beds available to those who cannot afford private rooms. The kernel of the problem in our health services is the fact that the frightful cost of hospitalisation is draining money from the health funds at an increasing rate daily.

There is now a much higher standard of housing throughout the country and the vast majority of them have hot and cold water. This should mean that the health of our people is better. Some years ago a brilliant Dublin surgeon suggested that mobile medical squads, as the maternity hospitals have, should be introduced in the city. He suggested that such squads consisting of highly qualified medical personnel could be sent to houses of patients in need of treatment. That could be done in the case of minor ailments and would result in a great number of beds being made available for major operations and intensive care. It would also reduce the huge cost involved in keeping a patient in hospital and eliminate the dispensary service in urban areas.

In the major cities there are many excellent health centres and they could be used by the medical squads as their base. Some of the hospitals are very old and, consequently, the cost of maintenance on them is very high. The establishment of such a squad based at health centres would reduce the need for such hospitals. Those centres would be welcomed by the people because they could obtain the services of a doctor there at any time. We have allowed the opportunity of establishing such centres pass and we are still clinging to the concept of hospitals, and we measure the value of such hospitals in their cost.

Our hospitals have set a tremendously high standard and we seem to take for granted the dedication of the staffs of those hospitals. We also take for granted the dedication of the men and women who serve as voluntary governors on those hospitals. I am glad to know that we have been able to attract some of the top businessmen of our city on to these boards. They are giving their time freely and willingly so that the hospitals can be run more efficiently. However, we should have a more localised auxiliary hospital service. In the big urban areas the centres I have suggested could operate on a 24-hour basis.

In relation to accidents the Minister should consider the establishment of a central accident hospital in this city. At present the hospitals in the city must keep beds available for accidents but if there was a specialised hospital for accidents the other general hospitals could carry on with the work they were intended for. It is difficult for ordinary people to know what hospital is on the register on a particular night for accident cases—the ambulance drivers have this information—and they tend to go to the nearest hospital to the scene of the accident, but it can happen that the accident case cannot be accommodated at that hospital although in emergencies the injured will be admitted. A central accident hospital would relieve the burden on the other hospitals. The proposed hospital would be specially equipped to cater for accidents. If health centres on the lines I have suggested were sited in various parts of the city, residents would be relieved to know that there would be somebody on duty there throughout the day and night. We would not have certain stories going around of people being unable to get a doctor to attend to their father, mother, son or daughter.

I should like to pay tribute to the religious orders who started many of the hospitals in this city some years ago. They were the pioneers in this type of medical care. We have always had dedicated people in the other hospitals. In fact, the Rotunda Hospital was the first maternity hospital in Europe. In this regard a Mr. Moss has left a wonderful legacy. I suggest to the Minister that he look at the possibility of sending a medical unit to the local health centres. If that was done, minor operations could be carried out in people's homes. The general hospitals would be glad to be relieved of the minor operations so that they could concentrate their efforts on major complaints. With the increased cost of hospitalisation and the scarcity of beds the Minister, instead of suggesting economies such as cutting back on geriatric services and other petty economies, should tackle the major question of our hospital system. He may then find a practical solution to the problem. We must face the fact that there is discontent in many of the hospitals. In this regard I should like to state that last week I noticed that flags were hanging from the windows of the Dublin Dental Hospital. There was a one-day squat in progress. It is deplorable that this should happen. I am not suggesting that the Minister is to blame but there is something rotten in our system when some of the staff of such a hospital hang protest banners from the windows of that hospital. There is not much use in condemning the people responsible for this protest; we must examine the situation and find out why they were driven to this. I have been told by some of those involved that the problem has been in existence for three years and that it involves a simple application to have a proper staff structure there.

We must also consider the position of the Federated Dublin Voluntary Hospital, an essential part of the hospital services of this city. There are six such hospitals including Sir Patrick Duns, Mercers, Adelaide, the National Children's Hospital, the Meath and the Royal City of Dublin Hospital. They will be closed eventually. This was the policy adumbrated some years ago. I think we should have another look at the whole matter now. I realise we cannot have duplication and triplication of costly equipment. We must have, to use that horrible word, rationalisation, but when these hospitals are closed there will be a void in different areas in the city because these hospitals are centrally situated and very convenient when accidents occur, particularly domestic accidents.

The tendency to bigger hospitals is growing all over Europe. Some of our hospitals have as little as 180 beds and the Minister can justify rationalisation by arguing that the cost of maintenance of these hospitals is too high. I agree it is. Some are in need of major repair. However, we should not lean too much on the financial side of the matter. They may be old but they are very renowned and they have helped to give Dublin the name it has as a city of very fine medical schools. I suppose there are few cities in the world with three medical schools, two universities and the College of Surgeons. There is also the College of Physicians. Dublin has a fine structure from the point of view of hospitals. Unfortunately, our generation is inclined to move away from tradition.

According to report, the Eastern Health Board have set up an economy committee. Economy means saving money. What we should be doing is saving lives. Contributions are made by insured workers through the medium of taxation, hospital sweepstakes and so on. Is there great waste? The Minister is on the wrong track when he seeks to cut back on items like cornflakes for patients. How much will be saved? Is this economy in operation? Does this happen?

It does, of course. He denied it but it is true. All these things are true, every one of them.

This report also says there will be simpler desserts after dinner and a cut down on minerals and soft drinks with meals. Being a non-drinker I am sensitive about this one. There is talk of a reduction in the cigarette allowance. One thing that has stopped is the taxis to take people to hospitals. I know this from personal experiences. There may have been abuses but someone once said that abuse of an art is no condemnation of it. What is the old person living alone, not properly mobile, to do now? Is she expected to use public transport?

Economy can be an economy on lives. I realise financing the hospital system is not cheap, but we seem to have gone overboard on economies. It should be possible to economise without depriving people of small amenities. Many institutions need money. There is one in my own area where the conditions approximate to those of a tenement. We cannot get a penny to build a new home for the women living in this building. I have been pressing the matter without publicising it too much. Publicising for the sake of embarrassing someone is not a good thing but the time is coming when we, on this side of the House, will have to spell out these things clearly and bring the situation home to the people. If we do not do that it may be taken that we support these economies.

Some hospital wards will not be able to keep open during the summer. I will send the Minister the details. If these wards are closed the result will be fewer beds available for patients. Tomorrow is the last day for renewing contracts with medical personnel under the school health service. I do not know whether or not these contracts are being renewed. If they are not it will be a national tragedy. This school health service is the only possible means whereby some children can be ensured proper treatment. It is imperative that children's maladies should be discovered as early as possible. If they are not there is bound to be a deterioration and that deterioration will ultimately prove far more costly to treat.

In our three medical schools we train many people who are not Irish and who will go away anyway. We also train our own and very often all we can offer them when they are trained is emigration. The country is taxed to the hilt to pay for education and we do not begrudge that. But it is crazy economics that we should invest in these men and women and that they should go away and serve suffering humanity elsewhere, when they would much rather stay here, for the major portion of their lives anyway. Some of them may emigrate in order to gain greater experience at some of the famous clinics throughout the world, and that is understandable. However, we should be able to guarantee a place in our hospitals to every doctor who graduates. To suggest that there are too many doctors is absurd. We have too few opportunities for them. Many doctors here are overworked and we are inclined to look for people from other countries to work cheaply for us in order to keep our system going.

I do not think people would cavil at being taxed further if this taxation was going to ensure such things as the maintenance of the school health service or a proper service for old people in hospitals. People object to further taxation when they feel we are only papering over the cracks in the health service when we vote here for extra taxation and then find that perhaps one section is worse off than another. Take for instance alcoholism, a problem which is assuming greater proportions all the time; or take the case of spina bifida children, cerebral palsy children or any other kind of retarded child, are we doing enough for them? I would say the Minister has a deep interest in the problem of retarded children, but good intentions are not enough. We must provide a very efficient service to ensure that these children get the best treatment possible.

Take a person who requires eye surgery. How long will it take from the time a person applies to the Eye and Ear Hospital before he can be admitted to have an operation carried out? I am not in the least criticising that hospital. In fact, I can only praise them for their efforts, but through no fault of their own a person may have to wait months for eye surgery because there are no beds or because the staff are overworked. Eyesight must be regarded as one of our greatest faculties, and an old person may be worrying about his eyesight deteriorating all the time he is waiting for hospitalisation. If a public representative makes inquiries at the hospital on behalf of an old person and he is told the situation, he accepts it; but he also remembers the old person living on his own who may not know a public representative whom he can talk to and who can try to get him early admission to a hospital. We cannot compliment ourselves on having made any progress while a person has to wait so long before being admitted to an eye and ear hospital.

Over the years the Eye and Ear Hospital has improved greatly and the staff there are extremely dedicated and must not be blamed for this situation. We must be blamed for it here because we cannot make money available to extend the hospital and for the employment of more specialists. The Minister may say we are condemning extra taxation while calling for more services. What we do call for is better services, and I am convinced this could be brought about by examining the whole range of health services and asking why a person must wait months to have eye surgery or why, as Deputy Haughey asked in a question here this afternoon, a person should be directed to leave an old people's home in the interest of alleged economy.

These things do not encourage the potential hospital patient to be at ease or to have complete confidence in our whole health system. The Minister has at his disposal the Department of Health and other ancillary bodies and he can look at the whole picture and see where the weaknesses are, while we on this side of the House must always do our duty by offering suggestions and by criticising. We must say unpopular things at times. Any politician worth his salt must not expect to have it easy all the time. The Minister may have to make unpopular decisions, but they should not be made at the expense of the old person in the geriatric home or the child attending the primary school whose only hope of having a good medical inspection is through his school being visited by doctors and nurses who may discover some ailment which can be diagnosed in a general hospital, so that the parents can be assured that there is a hospital bed available and that the child can get the necessary treatment.

It is accepted as a good thing that a mother should stay in hospital with a child who is a patient. In one institution with which I am connected this facility is being brought in. However, if hospitals are to provide such a facility more money is needed. One might well ask: who will mind the other children when the mother is away? The father may be out at work all day. Here again the local health service could be of assistance.

I never feel very happy when I visit our biggest geriatric hospital and see old people there in big long wards. Many of them are senile and some are not senile. It is a picture of suffering humanity, despite the dedication of the staff. I should like to see in every suburb of this city an old people's home with which the local community could be associated. They could meet the patients and take them out for walks. They could let the old people see that they are still a vital part of the local community and are not forgotten.

There are many old big houses in this city which are let go to rack and ruin. The Minister could acquire these houses and set up small local homes which would cater for 12 or may be 20 patients. If this were done we would not need the big hospitals we have at the moment. Many of those buildings were taken over from an older regime many years ago and did not have the facilities of the modern buildings. It is good to know that if an old person has no one to look after him he can be taken into an institution and cared for. We should put the emphasis on local homes. If the local people took an interest in these old people's homes, what a different society we would have. We have done a certain amount for our old people, but we have not done enough.

There are three pressing matters which need to be dealt with. The first is the school health service which not alone must be maintained but must be expanded to cover post primary schools. University students have medical cards. Families who cannot get the medical cards may quibble at this, but in my view it is worthwhile for those students to have medical cards. The primary school student may not have a school inspection for very much longer. I would like to see the school medical service expanded. When the school leaving age was raised to 15 years naturally more students came under that scheme but did we expand that service then? I doubt it. Nowadays more children are leaving school later. To sacrifice the school health service is false economy and must not be allowed to happen.

Some hospitals will not be able to give the services they have provided for hundreds of years. This position must be tackled if we are to save the hospitals. By his questions and supplementaries this afternoon Deputy Haughey has left the Minister in no doubt as to where the fault lies. His questions pinpoint the weaknesses in the system.

I would now like to discuss the cutbacks on certain items for old people. They may be small to us but they are important to the old people. An old person lying in a hospital may be deprived of the small gift given by the benevolent society if we cut back on this service. What does the Minister mean by economy? He should not feel happy just because he saves a few pounds; he must go deeper than that. He should ask his advisers, the teaching religious orders and the lay people: "What is wrong with our hospital service? What is wrong with our health services that we are making such a bad job of them?"

Unfortunately, because of the state of the economy, many of our workers have been made redundant. This is a tragedy for the people concerned. When we start making our doctors and nurses redundant there is something rotten in our society. An industrial worker may be made redundant because of a shortage of orders in the factory. Our doctors and nurses are being made redundant not because of a shortage of patients or hospital buildings but because of a shortage of money. This year some hospitals may have to turn away patients. This is not to be tolerated. I realise that the shortfall in hospital revenue between the amount given by the Department and that spent is not very great. This cutback will not only cause suffering but will mean that eventually more money will have to be spent to cure people whose health has deteriorated because of this economy drive. It is almost criminal to suggest that we cut back on our health services. There are far too many people, young and old, waiting to be treated. It is on the Minister that the onus rests to maintain proper health services and to improve them where possible. I hope, therefore, that he has listened to the suggestions I have made and to the intriguing questions Deputy Haughey asked earlier, so that faults may be remedied and that people will not suffer because of lack of proper health services.

One of my suggestions is that local health centres would be established to look after the different areas, that each such centre would have a team of doctors and nurses to treat people in their homes thereby reducing the demand on hospital accommodation which these days costs a minimum of £60 per week per person. We should be able to so gear our services that fewer people will have to go to hospital, thus easing the pressure on hospital accommodation.

We should be calling more on the wealth of knowledge and experience which hospital staffs have, be they run as general hospitals or by religious orders. In that way we could improve on the present health services. Our aim should be to ensure that no person suffers needlessly and that people's morale is not affected by the prospect of going to hospital and having to face the cost of it. For our old people there is need for proper geriatric homes in which they can be treated at the end of their days. In other countries we have seen almost total disregard for old people: societies became impatient with them and began to regard them as a burden. I hope we will never reach that stage, that we will never introduce a system which would disregard life either at source or coming towards the end. Life is sacred and we should at all times continue to regard it as such.

The Minister must therefore ensure that our health services will not be run down. Indeed the aim should be to expand them. Hospitals must be given the necessary money to provide the required services and therefore there should be no danger of a cutback in the services in 1976. I hope the Minister will find some assistance in the suggestions I have made and that they will lead to better health services for the country.

I hope the Parliamentary Secretary will inform the Minister of the points I am about to make. There are many contradictory statements coming from hospital boards of management, from doctors attached to hospitals and from the Department of Health, which cause me to worry. If one says publicly that certain things are wrong in certain hospitals, there is a public scare. We do not want that and I should like the Minister to take particular note of the fact that he has an independent team of medical men to advise him and to assess whether the comments made by doctors in hospitals are correct: that the conditions that prevail, for example, in an intensive care unit, are adequate, if you like, but not what they should be. If the Minister were to appoint an independent team of medical advisers to investigate the contradictory reports that appear from time to time— where, for example, medical doctors say that certain conditions are not what they should be and the board of management contradicts them—the Department of Health would then be able to assure the Minister that he has no need to worry. I know of this type of case. When these things become public they cause consternation. We do not want this to happen. The Minister should set up an independent team to inquire into complaints. I know that boards of management worry about making a fuss because they feel they will lose their place on the priority list when funds become available and that they may well be victimised by the Department of Health, that certain officials of the Department might make things hot for them. They will not admit that. The impression I have is that they will deny that. If the Minister hears that the facilities in a particular hospital unit are not up to standard it is important that he should get his own medical advisers to assess the situation. When the Minister gets a report like this he should have access to independent advice. I have no doubt that certain boards of management are afraid of losing their place on the priority list. If something costing £150,000 is within sight, the hospital may have to wait a long time before getting it and they may find themselves a long way down the priority list. That is not said to them, but it is a feeling they have and therefore they are afraid to draw attention to what might be a serious shortcoming. The Minister should think about setting up an independent board.

This debate has provided some useful information and constructive suggestions. For some reason many of the contributions were very unhelpful, not alone to the progress of this debate but to the health services in general. Of course, in a delicate social field like this there is always scope for political mileage and I think we have had that as far as certain contributions are concerned. There has been a lot of scaremongering, which does not do the service any good and certainly does not do the patient any good. As I said, this is a most sensitive area in the social field and a lot of damage can be done by the contributions made and by certain things reported through the media.

A lot of the complaints I have heard this afternoon with regard to dental services, child services, medical cards and the complaints of patients have been going on for years and years. This has been going on for quite a long time, even in a time when there was no real question raised in the House about the availability of money. The debate developed in the limited time available into an Estimate debate. I do not think anybody would expect me to go into the detail I was asked to go into in respect of certain aspects of the health services, but I will comment on some of the broad issues that have arisen.

Nobody dealt with the Bill itself in any great depth, but Deputy Ciarán Murphy asked certain questions which we might try to clarify. The weekly contributions are increased from 26p to 33p from 1st April and the annual contribution from £12 to £15 from 1st April. As I explained in my opening speech, the increases are related to income increases since the contributions were first fixed. I did not hear any grave objection to them. They were described as another tax, but the late Deputy Childers, when he introduced the original Bill in 1970-71, described the contributions as a supplement to the financing of the health services. This is the line on which I am proceeding in regard to these increases. They are, indeed, a very small amount compared to the overall expenditure in health services and they will continue until we have a new method of financing the health services. I think the increases are reasonable. I did not hear any serious objection to them. Contributions to the Department of Social Welfare and the cost of the stamp have increased with inflation. The payment of the health contribution is a very good investment for those concerned, particularly when one remembers that the actual contribution represents only about 6 per cent of the total cost to those who are described as being in the middle income group and who have limited eligibility.

The debate has been a general one. The provision of health care is a critical area in the State's responsibility towards its people. Indeed, it is not like any other Department that I know of in that it involves the whole population. Everybody is affected by health legislation and the general running of the health services. I do not pretend to have all the answers as far as health is concerned. For that reason, I believe that all Members of the House should sit and learn and not be indulging in tactics which do not help the health services.

Some contributions are worthy of special mention. The contribution by Deputy Seán Flanagan——

Deputy Flanagan did not contribute.

I am sorry. He contributed in the debate on 4th March. However, he did call for an evaluation of health expenditure. This was the most positive theme in the whole debate and it is essential in the light of the cost of the service, which at present is running at £262 million. That is a fair amount of money and an evaluation of health expenditure is necessary. There should be a continuous process whereby there would be an evaluation of the service. In 1976 18 per cent of the non-capital exchequer expenditure was devoted to the health services against 10 per cent or 10.5 per cent in 1971. I repeat that the increase related to gross national product in 1972 has risen from 4.8 per cent to 6.3 per cent. Therefore, it cannot be alleged that, as far as I or this Government are concerned, there has been any skimping in the allocation of money. It is essential to evaluate the ways in which we spend the money. It is essential to ensure that our now scare resources are devoted to the most valuable programmes. It is essential also to ensure that the money is not wasted.

Deputies on the opposite side of the House continue to talk about cutbacks. I prefer to call them economies and I think economies are right, economies that have been negotiated between the Department of Health and health boards with the CEOs and with the approval of five so far of the eight boards.

Was any health board allocation increased?

Therefore, they were not really discussion.

They were discussions about what economies could be effected. I never said any allocations were decreased.

The allocations were discussed. It was laying down the law.

It was not laying down the law. In consultation with the health boards these economies have been proposed and are in operation. Deputy Haughey, Deputy O'Connell and Deputy Esmonde believed in the need to evaluate our administrative structures to see that the services were to see that the services were administered effectively and economically. It is important that we should evaluate the administrative structures. I refer particularly to the health boards, and the need for programme evaluation and a general review of the administrative system. These are all good ideas that are worthy of consideration but the problems that we have here as far as health is concerned and as far as evaluation of programmes is concerned are not peculiar to Ireland. As Deputy Haughey himself pointed out, these are debated all over the world and there does not seem to be, as yet, any perfect solution. I am trying to improve these procedures in administration and in programme evaluation, particularly in view of the fact that so much money is being or has been devoted to the health services. It was for that reason that in 1973 there was established in the Department of Health an organisation unit and part of their functions was to improve the administration in the Department of Health itself. The unit also undertook some work with health boards to improve their financial control and their budgetary arrangements to ensure that the money was spent in the best direction and with the best results. The organisation unit also undertook pilot studies in hospitals regarding the administration systems therein and on the steps necessary to improve them.

I do not believe we can get overnight results in this evaluation, in these examinations and in these controls but there must be an effort and a start to this process. Results, and good results, will show in time.

Much work has been done in the last few years towards improving administration in the health services, and the organisation unit will be strengthened to speed up an improvement in those fields. There has been a positive start in St. Finbarr's, the health board hospital in Cork, and there is work going on to see where improvements in the running of the hospital can be achieved. If that experiment, so to speak, is successful it will be possible then to apply the findings or the recommendations or the results to other hospitals. I may say, also, because people talk about the high cost in certain areas, that the study is also being undertaken in conjunction with the Mater Hospital to see how their financial controls and budgetary methods can be improved. Here, again, in this exercise we hope to learn results which can be applied to other voluntary hospitals. Therefore, the House can be assured that as far as these two matters are concerned, evaluation of costs, cost benefit and general administration, the start has been made in respect of the health board hospital in Cork, St. Finbarr's, and the Mater Hospital in Dublin.

Deputy O'Connell spoke about the necessity to look at the individual services to see if the results are commensurate with the amount of money we spend on them. I think there is a growing awareness, and this was mentioned in the House some time last year, of the need for a shift in resources towards those services which will yield the best overall results in terms of the health of our community. That was the general consensus of opinion of those who attended the seminar in Waterford last May. To them it meant, and rightly so, the shifting of resources from the hospital system to the individual services to ensure that people would be kept out of hospital where this was possible, because, as Deputy Moore has mentioned, the cost of the maintenance of any person in hospital per week represents a colossal amount of money. Therefore, that is another matter that should be examined with a view, not necessarily towards making economies but shifting the resources towards the services which will yield the best results.

However, it is apparent from the debate and various debates that we have had over all the years that the demands on the health services are limitless. If there were no criticism by the Opposition on the amount of money being devoted to the health services now, there still would be, not alone from the Opposition but from this side of the House, demands, as there have been for a long time, for improvements in the health services. It appears that it is a never-ending demand and if our resources are not there we have to make the proper choice, a choice as to where we will devote the money in order to do the best thing as far as the health services are concerned. There has been a gradual improvement in administrative arrangements of our health services and this should lead to more effective choices being made in respect of the shift of financial resources.

I also propose to strengthen as soon as possible the planning unit in the Department of Health so that it can play a greater role in evaluating the benefits of individual health schemes. There has been not alone in this debate but in other health debates an inference, a suggestion, sometimes a positive allegation, that our health boards are not working properly. Deputy Haughey and Deputy O'Connell, and in another debate, Deputy Seán Flanagan suggested there was need for a review. Most of those who participated in the debate, if they did not stress it, mentioned the need for a review of the health board system. I am certainly not opposed to that in principle.

I did not prejudge the issue. I did not say that I agreed with any ground for criticism. Some other speakers did, I did not.

I do not want to give that impression in regard to the Deputy but he did mention the question of a review. While not opposed in principle to this review I should like to make a few points about the health boards. Contrary to what was said, I think by Dr. O'Connell, they were not established on the McKinsey recommendation; he came in after the establishment of the health boards. It was this Parliament and no outside agency that established them. This Parliament passed the Act setting up the health boards and subsequently defined the composition of the administrative offices with the concept of a chief executive officer and so on. The establishment of health boards remains the responsibility of Dáil Éireann as determined in 1969 before McKinsey came on the scene. McKinsey's job was to advise on top management structures and the general management methods of boards, such as programme managers, personnel officers, accounting officers and so on. The boards were our own creation.

There seems to be an impression abroad, not necessarily in respect of health boards but in respect of many Government Departments and institutions that there are enormous bureaucries at the top. I do not know what "enormous" means in the context of health services but my information is that there are about 50 people involved in top management. I am talking about people such as programme managers, CEOs, accounting officers and personnel officers. Deputies opposite will know what I mean; I am not including clerks, typists and so on. I have been told that since the establishment of the health boards, two other people were recruited—I cannot say in what capacity. People talk of the enormous number of bureaucrats at the top of the health service but my information is—and I have no reason to doubt it—that at present there are 52, comprising such people as CEOs. programme managers, accountants and personnel and planning officers.

Fifty-two between the eight boards, an average of six per board?

Yes, in the particular brackets I have mentioned. Deputy Haughey seems to think it is a very small number for eight boards and so it appears to me also. We must remember that they are spending £175 million this year and this is not an excessive number when one considers the amount of money they must control and the wide field of services provided.

Neither should we assume that because health expenditure has gone up considerably since health boards were established this is necessarily a consequence of their establishment. Much of the increased expenditure since 1971 arises from increases in wages, inflation and development of the services since the establishment of the boards—I do not say that in respect only of the last three years, but development has continued in the last three years.

As regards the health board system itself. I can see three options of which some would not be either feasible or desirable. It has been suggested that we should revert to the county system; that we should evolve an entirely new system and that we should improve the present system. I believe the most practical, sensible and logical thing is to improve the present system. The boards have been established for approximately five years and McKinsey said in his report that the health boards structure should be reviewed after five years. The five years are now up, as the boards were established in 1971, and it is only natural to have a review. I want to make clear to those involved in the health boards that any review, as far as I am concerned, would not be any reflection on the staff or their competence or dedication. I should like to emphasise that the review would not be in the nature of a witch hunt.

We must consider how that review should be carried out. Some might suggest an outside agent like McKinsey. Different opinions have been expressed about the method of review and about what the personnel of the review team or committee or working party should be. There could be a special departmental team with outside consultants: there could be a team of outside consultants on their own and, as has been suggested here in a positive way, there could be an all-party committee of Deputies, a Committee of the House. It was also suggested that it might be done by a body representative of all parties with representatives of the professions within the health service, the Administration and the Department. I certainly subscribe to the idea of a review but I would not like to come down this evening in favour of any one of these options. At present I do not think that an all-party Committee of the Dáil would be sufficient. Deputy Haughey was in the House on another occasion when an all-party Committee was set up and I do not think the results were conclusive. If they were, they were certainly not very fruitful. That is no reflection on those who participated but possibly it was due to the fact that the proper people were not involved in consultation or in the giving of information. I know that many people made submissions to the Committee, individuals and bodies like trade unions, industrial firms, and so on. I would say yes, as regards the review but I should not like to commit myself now as to what the format of the review body should be.

In speaking of the income limits Deputy Haughey argued that there should be uniformity in so far as manual and non-manual, insured and non-insured were concerned. At present, there is no limit in respect of the insured manual worker but there is a limit for non-manual workers. This anomaly has existed down through the years and I agree that it should be abolished as soon as possible but it can be abolished only in two ways. We could either abolish the income limit for non-manual workers to bring them into line with manual workers or we could impose an income limit on manual workers in the same way as for non-manual workers. I would not favour that and neither would I think Deputy Haughey would advocate in because it would mean an income limit for manual workers in respect of whom none such limit existed previously. Therefore, a solution may be not to impose a limit on manual workers but to abolish the present income limit for non-manual workers and all others. That would be a reversion of the policy of which Deputies are very sceptical—free hospitalisation in a public ward for all, a proposal which has been described as doctrinaire and which has been criticised by various people. I made that suggestion in good faith and in the belief that it was the proper move to make on the basis that if people wished for private or semi-private accommodation they should pay for it but that there should be the choice for all of going into a public ward. There have been snags in this regard. I have no hesitation in saying that the medical organisations were opposed to this suggestion and for that reason, as I have told the House frankly, I propose to postpone the idea and am awaiting the report of the review body established about 18 months ago. Until we know their recommendations it will not be possible to implement the scheme but its implementation would entail discussions also with the medical associations.

Would the Minister agree that a free-for-all is practicable?

It would be practicable if we had the money.

It is really a question of facilities.

Deputy O'Connell talked about the income limits and asked whether it was true that 300,000 additional people would be brought in as a result of the raising of the limit. I do not know from where anybody got that figure but the answer is "No". The new limit I propose would be £3,000 and this is only an adjustment in line with the wage agreement adjustments that have occurred since the limits were fixed last—that was in April, 1974, in respect of insured non-manual workers—and in respect of those who were limited by income to £1,600 per year as fixed in October, 1971. Therefore, all I am doing is ensuring that those covered already for limited eligibility will continue to be covered from the 1st July onwards in the case of insured women and from the 1st January, 1977, in so far as insured men are concerned. In all, there will be 85,000 people involved, this figure being made up of 5,000 insured women, 30,000 insured men, 40,000 dependants of those insured men and about 10,000 who are restricted by reason of income limits and valuations.

Deputy Haughey availed of the debate—I am not complaining about this as it is his right—to raise again the question of economies being made by the health boards in the current year. This issue was raised by way of Private Members' motion and also by way of parliamentary questions during the past two weeks. It is not my intention to go over the entire ground again and to repeat what I said by way of reply either to the parliamentary questions or to the supplementaries which were asked subsequently. However, the Deputy hinted that there was some kind of collusion between the Department of Health and the CEOs in eliminating the so-called deficits by specifying economies. That was unfair of Deputy Haughey who seemed to imply, also, that the CEOs are "my men".

I have had various discussions with the CEOs both as individuals and as a group and I could not describe them as "my men". They are men who are highly intelligent and reputable and who take their own decisions. Of course, they must work within the allocations given to their respective health boards but I wish to make it clear that their statutory responsibility is to the health boards and not to me or to the Department of Health. It is not my belief that the CEOs would fail in their responsibility to the health boards by agreeing to adjustments in their estimates which they considered to be unreal.

I find it difficult to believe that a deficit of £3.7 million could disappear on paper.

I explained that either to the Deputy or to Deputy Burke by way of reply to a parliamentary question about a month ago. I do not say, either, that CEOs produce irresponsible estimates. The reconciliation of estimates and the allocations made were due partly to repricing of certain items and partly to economies which I have described already. Also, in the preparation of their estimates they underestimated their receipts. Already I have given the House the various items which reduced the estimates by a considerable sum of money but Deputy Haughey does not appear to believe in housekeeping economies.

That is a different point.

The Deputy's simple solution is for me to go to the Government and get another £10 million or £15 million.

I have told the Minister that approximately £15 million would right the situation totally for this year.

The Deputy might as well have said £20 million.

I worked the figure out for the Minister.

May we hear the Minister, without interruption please?

We are not fighting but merely exchanging views.

The Deputy does not seem to believe, regardless of anything that has been said, that there is the possibility of effecting economies in the health service. Some members of Fianna Fáil, in addition to individual members of the other parties have expressed the view that there was room for economies. One may talk of small economies but they all add up. I recall Deputy Connolly some time ago talking of the expensive advertisements placed by health boards in the national papers implying that there could be a cutting-down in this regard. That is one small example but I shall refer to others in a few moments. We should think in terms of economies. I have not in mind any diminishing of patient care or of harming patients in any way but I have been accused in this House during the past few days of almost everything from wanting to kill babies to knocking off old people.

If the Minister wants the Committee Stage this evening he would want to give us some time for it. It is the type of economies we are questioning.

In any case I think Deputy Haughey has a very short memory. He is very generous now. He is very forthcoming now as far as the health services are concerned but he was not so forthcoming in 1969. I should like to quote from the circular sent from the Department of Health to the then county managers. The reference is: HSG 221, 12/2/1969. This was from the Department of Health.

I never heard of it. I never saw it.

I know the Deputy never heard of it. The Deputy is wasting my time. The circular states:

I am directed by the Minister for Health to state that he has had under consideration the question of the incidence of the cost of the health services in the year 1969/70.

This is 1976. What has 1969 to do with it?

It was a very important year for the Deputy and 1970 was much more important.

So was 1798.

The Deputy was not around in 1798. He was in 1969-70.

Order. Will the interruptions cease?

The circular continues:

The matter has been the subject of discussion with his colleagues in the Government and, while the question of sources of financing the services additional to the Exchequer and the rates continues to be examined, he wishes to indicate to health authorities the situation which will obtain in the coming financial year. On the basis of the estimates submitted by health authorities the total cost of the services in the year 1969-70 will show an unprecedented increase over the cost of the current year. The total revenue expenditure of health authorities in 1969-70 will be in the neighbourhood of £49 million as compared with the figure of £41 million as originally estimated in respect of the current year. It is particularly disturbing that this situation should be expected to develop in a year in which no substantial extensions to services are being budgeted for. The Minister for Finance——

The Deputy did not know this one.

——shares with the Minister the consciousness of the very heavy burden which the local rates impose and of the requests from many sources that the Exchequer come to the assistance of the ratepayer by extending existing subventions towards the health services for the relief of rates. The Minister for Finance, has, however, already made known publicly that the Exchequer is facing a very difficult situation in the coming budget. Substantial increases in the estimates for the public services as a whole indicate a level of expenditure for 1969-70 which altogether outstrips estimated revenue. Unless very large economies are effected further increases in taxation will be necessary. Such increases are unpleasant in themselves but more importantly they could at this stage put a serious restraint on growth in the national economy.

He goes on and on. The conclusion of the letter is:

The Minister feels that in the health services substantial economies can be found without detriment to the efficiency or availability of the present services.

Which Minister felt that?

This was the Minister for Health in a circular to the county managers.

I was not Minister for Health.

The Deputy wants to disown the Minister for Health. He was part of that as well. That is how Deputy Haughey felt.

(Interruptions.)

Order. The Minister should be allowed to make his contribution.

How does the Minister intend to make up the deficiencies?

As far as I can see the health boards are not seeking to make political capital out of this situation. There are no wild allegations being made by them. They have acted responsibly and that is demonstrated in the way they have accepted the recommendations of the CEOs. Deputy Haughey does not seem to be so responsible. He still trots out, even today, allegations of: "widespread cuts"; "age for free milk to be reduced". I refuted that weeks ago. "Welfare allowances to be cut." I refuted that. "Means test for constant care allowance to be introduced." Wrong. I told him that. "Routine health examinations to be done away with." Wrong. I told him that. "Fifty beds to be closed in three major Dublin hospitals." Wrong. I told him that. He doubted if the GMS would be maintained. I had occasion to tell him it would be 19 per cent extra.

The Deputy then went on to Saint Loman's. We had this again in the course of the whole debate. We had jibes and jeers. There was the original report in The Irish Independent with a lurid heading: “400 mental patients are put on hard times diet—a spokesman”. We were told that this would throw us back to the dark ages and impose hard times workhouse conditions on patients. I would like the Deputy to look at an extract from The Irish Independent which is headed: “Health cutback despite denial”. I would like to read out some of the things in that report. This was investigated by a Mr. Jim Farrelly and he was interviewing a man named Mr. Keyes.

The Minister will not get his Bill this evening.

Is the Deputy imposing a time limit on it?

The Minister wants his Bill by 7 o'clock and we have to do Committee Stage yet.

I do not know what time the Deputy wants for Committee Stage. I would like to read some extracts from this report. It stated:

The claim: Cornflakes have been cutback at breakfast.

Mr. Keyes: Cornflakes were freely available at breakfast before, along with porridge. A number of patients were getting both at breakfast. I do not have two cereals for breakfast. If a nurse is aware that a patient does not like porridge he is free to give him cornflakes instead. It is true cornflakes are not as available as before.

The claim: A cutback on minerals and soft drinks with dinner.

That was terrible.

That is wrong.

(Interruptions.)

Order. Let the interruptions cease.

I do not know whether or not Deputy Haughey saw this.

I have the report of the journalist who interviewed Mr. Keyes.

The Deputy has the original one, but he has not this one. The end of the report states:

Mr. Keyes parting shot was: "We have a responsibility to the patients and their relatives. I am prepared to admit the economies. But we are still providing as good a service as ever. Indeed we have improved the service since last year by expending money on occupational therapy in St. Loman's and a day centre at Usher's Island."

There are other things I would like to say. I would like to conclude by referring to something Deputy O'Connell said. Although critical of me at times, his speech was constructive and objective. He made a comment about the Department of Health. He seems to regard the Department of Health as a powerful deciding body who act as a power in their own right. I should like to refute that suggestion. He says he has held this attitude since 1960. If so, that is an indictment of the various Ministers who have been here since 1960. During the last three years since I have been in contact with the senior officials of my Department, I received advice which I sometimes accepted and sometimes rejected. When the decision was made the officials implemented the policy as decided by me and, I am sure, that decided by other Ministers under whom they served. I found them to be loyal.

This seems like the Minister saying farewell to the Department.

A Deputy

Is the Minister resigning?

I will not be asked to resign anyhow. I found the officials in the Department to be loyal, intelligent and dedicated, not alone the senior staff but the junior staff as well. I believe they are committed to the health services and their development. Whatever shortcomings exist in the Department of Health, let me be blamed for them. I will take the blame. As far as the officials are concerned, they serve me loyally as I am sure they have served other Ministers in the past.

Before we take a decision on Second Stage I want to know from the Minister are the allocations made to the different health boards final and can they be increased under any circumstances.

They are final.

Will they not be increased under any circumstances?

They are final.

We will have to vote against this measure as an indication of our disapproval.

Am I in order in asking a question?

A brief question.

The Midland Health Board cannot continue to give the service they gave last year without £400,000 more. The CEO has told us that. What is the Minister's comment on that?

My information is that the Department of Health and the officials of the health board are still in consultation in regard to the amount of money for which it would be possible to run the health services in the midland region.

With regard to the consultations going on between the officials of the health boards and the officials of the Department surely the result of those consultations means either severe cutbacks or, if the services are to be the same as they were last year, additional funds?

The endeavour is to make economies, not cuts.

(Interruptions.)
Question put.
The Dáil divided: Tá, 65; Níl, 61.

Tá.

  • Barry, Peter.
  • Barry, Richard.
  • Begley, Michael.
  • Belton, Luke.
  • Belton, Paddy.
  • Bermingham, Joseph.
  • Bruton, John.
  • Burke, Dick.
  • Burke, Liam.
  • Byrne, Hugh.
  • Clinton, Mark A.
  • Cluskey, Frank.
  • Collins, Edward.
  • Conlan, John F.
  • Coogan, Fintan.
  • Cooney, Patrick M.
  • Corish, Brendan.
  • Cosgrave, Liam.
  • Costello, Declan.
  • Creed, Donal.
  • Crotty, Kieran.
  • Cruise-O'Brien, Conor.
  • Desmond, Barry.
  • Desmond, Eileen.
  • Dockrell, Henry P.
  • Dockrell, Maurice.
  • Donegan, Patrick S.
  • Donnellan, John.
  • Enright, Thomas.
  • Esmonde, John G.
  • Finn, Martin.
  • FitzGerald, Garret.
  • Fitzpatrick, Tom (Cavan).
  • Flanagan, Oliver J.
  • Gilhawley, Eugene.
  • Governey, Desmond.
  • Griffin, Brendan.
  • Hegarty, Patrick.
  • Jones, Denis F.
  • Keating, Justin.
  • Kelly, John.
  • Kenny, Enda.
  • Kyne, Thomas A.
  • L'Estrange, Gerald.
  • Lynch, Gerald.
  • McDonald, Charles B.
  • McLaughlin, Joseph.
  • McMahon, Larry.
  • Malone, Patrick.
  • Murphy, Michael P.
  • O'Brien, Fergus.
  • O'Connell, John.
  • O'Donnell, Tom.
  • O'Leary, Michael.
  • O'Sullivan, John L.
  • Pattison, Séamus.
  • Ryan, John J.
  • Ryan, Richie.
  • Spring, Dan.
  • Staunton, Myles.
  • Taylor, Frank.
  • Timmins, Godfrey.
  • Toal, Brendan.
  • Tully, James.
  • White, James.

Níl.

  • Allen, Lorcan.
  • Andrews, David.
  • Barrett, Sylvester.
  • Blaney, Neil T.
  • Brady, Philip A.
  • Brennan, Joseph.
  • Breslin, Cormac.
  • Briscoe, Ben.
  • Brosnan, Seán.
  • Browne, Seán.
  • Brugha, Ruairí
  • Burke, Raphael P.
  • Callanan, John.
  • Calleary, Seán.
  • Carter, Frank.
  • Colley, George.
  • Collins, Gerard.
  • Connolly, Gerard.
  • Crinion, Brendan.
  • Cronin, Jerry.
  • Crowley, Flor.
  • Daly, Brendan.
  • Davern, Noel.
  • de Valera, Vivion.
  • Dowling, Joe.
  • Fahey, Jackie.
  • Farrell, Joseph.
  • Faulkner, Pádraig.
  • Fitzgerald, Gene.
  • Fitzpatrick, Tom (Dublin Central).
  • Flanagan, Seán.
  • French, Seán.
  • Gallagher, Denis.
  • Geoghegan-Quinn, Máire.
  • Gogan, Richard P.
  • Haughey, Charles.
  • Healy, Augustine A.
  • Hussey, Thomas.
  • Kenneally, William.
  • Kitt, Michael P.
  • Lalor, Patrick J.
  • Leonard, James.
  • Lynch, Celia.
  • Lynch, Jack.
  • McEllistrim, Thomas.
  • MacSharry, Ray.
  • Meaney, Tom.
  • Molloy, Robert.
  • Moore, Seán.
  • Murphy, Ciarán.
  • Nolan, Thomas.
  • Noonan, Michael.
  • O'Connor, Timothy.
  • O'Leary, John.
  • O'Malley, Desmond.
  • Power, Patrick.
  • Smith, Patrick.
  • Timmons, Eugene.
  • Tunney, Jim.
  • Walsh, Seán.
  • Wyse, Pearse.
Tellers: Tá, Deputies Kelly and B. Desmond; Níl, Deputies Lalor and Browne.
Question declared carried.
Agreed to take remaining Stages today.
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