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Dáil Éireann debate -
Thursday, 29 Apr 1976

Vol. 290 No. 3

Vote 50: Health.

I move:

That a sum not exceeding £249,983,000 be granted to defray the charge which will come in course of payment during the year ending on 31st day of December, 1976, for the salaries and expenses of the Office of the Minister for Health, including Oifig na Ard-Chláraitheora, and certain services administered by that office, including grants to health boards, miscellaneous grants, and certain grants-in-aid.

As is now the established practice, I have circulated a volume of statistical material on the health services and on the population which they serve. It contains a statistical description of the different programmes as well as information on population structure and on vital statistics. I arranged that Deputies would have copies of this document in advance of this debate so that they would have the opportunity before this debate of having up-to-date information.

I might mention that I am thinking of having the statistical volumes for this and future years published and placed on sale, so that they will be generally available.

When this Government took office in 1973, it committed itself to securing that there would be considerable improvements in our social services. Few would deny that this undertaking has been fulfilled within the limits of our resources. In particular, the Government undertook to remove health charges from the rates on a phased basis. This undertaking has been almost fulfilled by now and there will be no charges for health on the rates in 1977.

As well as fulfilling this undertaking to remove health charges from the rates very generous additional provision has been made to enable health services to be developed at an unprecedented rate. Growth rate in real terms over the three years up to 1975 was 16½ per cent considerably in excess of the growth in the economy generally.

It was inevitable that in considering what could be provided for Health in 1976 account would have to be taken of the serious economic difficulties facing the country, of the competing claims of other branches of the public services and of the very real development in the health services in recent years which I have mentioned. The Government had to think in particular of the need to give reasonable priority to job creation and preservation, national security and social welfare.

While it was not possible to provide for continued growth of health services in real terms in 1976 it should be noted that the Health share of over-all non-capital Exchequer allocations is not less than it was in 1975. The total non-capital allocations provided in the 1975 Estimates for all services was £960 million. The Health share, excluding capital, was £171 million or about 18 per cent. Of the total non-capital Exchequer allocations of £1,347 million for 1976, Health got £242 million, which is also 18 per cent of the total.

In 1976, therefore, the general aim is to maintain services at 1975 levels. Because of the circumstances which I have mentioned, it was recognised that growth in real terms in the health services in 1976 would not be possible. I have admitted this before. Because of the considerable expansion of services undertaken in recent years, our health services are better geared to face a relatively brief period of pause than would otherwise have been possible.

The response to my appeals to health agencies to make every possible effort to maintain services at 1975 levels has been encouraging. Health boards, which have been the subject of so many criticisms and strictures, have demonstrated their willingness to get on with the task of effecting reasonable but necessary economies. So have other health agencies. I would like to take this opportunity of thanking them publicly for their efforts.

It has to be accepted in present circumstances that no health agency can be free to determine on its own what its expenditure programme will be. Control of expenditure programmes is unavoidable. Good management postulates that constant reviews of expenditure and budgetary allocations take place and that reasonable remedial action is taken if this should become necessary.

There has been much talk about whether we are getting value for money. One of the primary tasks of management is to review expenditure in detail, to effect economies where this is possible and to eliminate waste wherever it is found. This tightening-up process will ensure that value for money is being obtained on the existing pattern of services. A further task of management is to review existing expenditure patterns and evolve proposals for diverting some of its resources to areas where it is considered that greater benefits would result.

I indicated in a reply to a Dáil question last month that in response to suggestions from health boards I was considering making certain changes to the existing health services regulations to provide for the amendment of the base figures which apply in the case of the scheme for the subsidisation of drug purchases. Regulations have now been made and will be laid before the House. The effect will be to increase the levels fixed in April, 1972, in line with changes in the consumer price index since that time. I am satisfied that it is a reasonable approach and consistent with similar action taken in other spheres of activity.

I should perhaps mention at this stage that, in accordance with the statutory requirements contained in the Health Act, 1970, I am arranging to have copies of the audited abstracts of health boards' accounts in respect of the years 1971-72 and 1972-73 laid before each House of the Oireachtas.

The health boards assumed responsibility for the administration of the health services on 1st April, 1971. Their first accounting year was the financial year 1971-72. The audit of the accounts for the years 1971-72 and 1972-73 was only recently completed in the case of each of the eight health boards. The audit of the accounts for the year 1973-74 and the period April-December, 1974, is expected to be completed in the present year, and the audit of the accounts for 1975 will then commence. There were a number of factors which delayed the completion of the earlier years' audits. As Deputies will appreciate, some considerable time elapsed before the newly constituted health boards could recruit the appropriate staff and were in a position to organise their accounting systems and procedures on a centralised basis. Indeed, for the first year or so of their operation much of the administrative work of the boards was discharged for them by the former local health authorities on an agency basis. These problems have now been resolved, however, and, as I have mentioned already it is hoped to catch up with the arrears of audit during the current year.

The abstracts of accounts as presented to both Houses are in the format which obtained for local authorities generally prior to the establishment of the health boards. This format has been continued as an interim arrangement but a working party which I set up last year are at present examining the question of a standardised form of accounts more suited to health board requirements. I understand that good progress has been made by the working party and that it is expected that these standardised forms of accounts will be prescribed for 1977 and ensuing years.

I should now like to turn to the specific developments in the past year in the various services. First, I will deal with general issues on eligibility.

As I explained recently to the House, I propose that the level for limited eligibility for health services be raised to a uniform level of £3,000 and I have circulated draft regulations for the approval of the House, with some explanatory notes. This is a complex matter but I will try to explain the essentials of it as simply and as briefly as I can.

Persons with limited eligibility are entitled to certain health services, principally hospital in-patient and out-patient services. The categories who come within the "limited eligibility" definition are, first, insured workers and their dependants, secondly, farmers with a valuation of £60 or less and, thirdly, other non-insured persons. Different rules for calculating eligibility apply to each of these.

Insured workers and their dependants make up about 70 per cent of the total eligible and I will deal with them first. They can be divided as between manual workers and non-manual workers. For the manual workers, there never has been and there is now no income limit, so that the change to £3,000 a year which I propose does not affect them in any way.

For non-manual workers, the limit originally fixed in 1953 at £600, has been adjusted from time to time to allow for wage rounds, and so on. The present limit, which was fixed in April, 1974, is £2,250. General increases in pay since 1974 would now equate that figure of £2,250 to a current one of about £3,000 or, perhaps, somewhat more. Non-manual workers who were in the less than £2,250 category in 1974 are thus now in the less than £3,000 category. A number of them have already passed over the existing limit, but they are still eligible because they retain their eligibility for a period of time after their remuneration exceeds the limit. For many this extension of time for eligibility is running out, however, and if the present limit were not increased an estimated 5,000 female insured persons would lose their eligibility by next July, while the total number of insured persons and their dependants who would have lost their eligibility by the end of the year, when the contribution year for male insured workers changes, is estimated to be of the order of 85,000.

The proposed limit of £3,000 is designed to retain eligibility for most persons who already have it and who have had no relative improvement in their financial position. It has been pointed out to me that there may be cases where the income of eligible persons has exceeded the £3,000 limit due solely to increases under the terms of the national wage agreements. I am looking into this anomaly to see if, in the detailed regulations on the entitlement of insured persons, it will be possible to cover it.

For the second category of those with limited eligibility—farmers— where entitlement is tied to land valuation, the change in the income limit will not affect eligibility in any way.

For the third category—other non-insured people—the present limit of £1,600 a year goes back to 1971. For these, entitlement is related to the income tax year and a continuance of eligibility after the income limit has been exceeded does not operate as it operates for the insured. Because the present limit for these people has so clearly gone out of date, the chief executive officers of the health boards have been applying the "hardship provisions" liberally so that, in reality, the fixing of a new limit of £3,000 a year would but formalise a situation which has been largely established by administrative practice.

Taking the pattern as a whole, the proposed change in the limits will not give rise to any substantial change in the proportion of the population which has been traditionally eligible for these services, which is about 85 per cent. In effect, this change will maintain the limit at its traditional level in real terms. Discussions have been held with the medical organisations, so that they will be aware fully of what is involved in this change.

What is involved here is a "holding operation" to maintain the existing levels of eligibility. I hope the House will see its way to approve of the draft regulations before it.

To turn to the full eligibility group, which is the group entitled without charge to all the health services, admission to this group is decided by the chief executive officers of the health boards. The chief executive officers fix uniform limits, which they use as guidelines in deciding on applications for medical cards. These limits make allowance for whethere a person is married, the number of his dependants and for fixed outgoings on his house. They are now standard for all areas. They are reviewed regularly so that they can be adjusted to keep pace with inflation.

During the past 12 months, because of the rapid rate of inflation, the income guidelines were reviewed twice—in July, 1975 and again in January, 1976—and they were increased to compensate for increases in the cost of living. The total number covered by medical cards at the begining of 1975 was 1,083,136, or 35.1 per cent of the population: at the end of 1975, it was 1,162,386, or 37.2 per cent.

The number of patients treated in our acute general hospitals continues to increase steadily but this has not led to any substantial increase in the total number of hospital beds, because the average duration of stay in hospital has declined noticeably. In 1960 there were 16,204 hospital beds. A total of 254,000 patients were treated in that year and the average duration of stay was 18.7 days. In 1974 the number of beds had increased only slightly to 16,478, but the number of patients treated had increased to 435,000—an increase of 71 per cent. This was made possible by a decline in the average duration of stay from 18.7 days in 1960 to 11.6 in 1974. This indicates more efficient use of our hospital facilities and we will continue in the future to study measures to improve this still further.

I would instance some work on hospital management in Cork which was sponsored by the Department. The new Cork Regional Hospital will be completed and should be ready for commissioning in 1978. This will be the largest general hospital in the State, with 600 beds covering practically every medical and surgical specialty. It is likely to cost more than £5 million a year to run.

To prepare for the efficient management of this new hospital it was decided to engage a firm of consultants to examine the organisation and management of St. Finbarr's Hospital, Cork, the staff of which will be transferred to the new hospital when it opens.

The purpose of the study, which commenced last year, is to develop effective management systems which can be transferred to the new Cork Regional Hospital. It will clarify lines of authority and responsibility within the hospital. It is expected that valuable lessons are being learned which should help to improve the efficiency of hospitals in the future.

Though all hospitals and health boards were given increased allocations in 1976 over 1975, quite a number of hospitals had to introduce economy measures to keep within their allocations for 1976. This has been a difficult exercise for hospital managements and staff. But it is not without some compensations, in so far as it has made everybody more cost conscious and more aware of the need for economies. It has helped to concentrate people's minds on the selection of priorities. These are worth-while lessons to learn, particularly in relation to hospitals, which are expensive to run.

The range of hospital equipment increases regularly and also the scope of medical and surgical treatments. In short, hospital administrators and consultants are involved in very complex and expensive organisations which require efficient and economic administration.

When I introduced the Supplementary Estimate for my Department in December last, I made a detailed statement on the Government's decisions in relation to the future development of general hospitals in this country. I dealt at some length with the comprehensive consultative process which had been undertaken and the reasons why the various decisions had been made. I should now like to inform Deputies of the progress which has been made since then in the implementation of those decisions in each of the health board areas.

It is accepted that for many reasons the development of general hospitals in the Dublin area is particularly difficult. I considered it essential that there should be a rational approach to the development of specialities in and between the major hospitals in Dublin. This is being considered by a joint Comhairle na nOspidéal/Department of Health Working Group who are considering the development and allocation of specialities in and between the Dublin hospitals. I understand that the group have made good progress.

In the meanwhile, it has been possible to progress on other aspects of the development plan in Dublin. A project team established to prepare a planning brief for the development of St. James's Hospital have been meeting regularly since October, 1975. The planning of St. James's Hospital is a complex issue but I am informed that good progress is being made by the project team.

As Deputies are aware, the development plan called for two new hospitals in Dublin—one in the Beaumont area and one in the Newland's Cross area. Negotiations have been in progress for a site at Beaumont Convalescent Home and the owners, the Sisters of Mercy, have agreed in principle to the acquisition of the site. Discussions have also taken place with Dublin Corporation regarding town planning and service matters in relation to that site. These discussions have proceeded satisfactorily and I hope that progress can be made on the negotiations for the site. Various sites in the Newland's Cross area have been examined as to their suitability for the siting of a major hospital and I am hopeful that a suitable site can be obtained there.

It is important that the decisions taken under the plan should be implemented in a co-ordinated fashion throughout the country; this is particularly important at present to ensure that the available resources are distributed in an ordered and equitable manner between the health boards. To achieve this I decided that a priority for development should be designated in each health board area and that the planning processes should begin in respect of these priorities as soon as possible. Discussions have been held with all health boards regarding the identification of these priorities and agreement was reached in most areas. I hope the position will be resolved in the other areas shortly.

The three main stages in planning are—agreement between the relevant health board and my Department as to the bed complement of the proposed hospital; the establishment of a project team representative of the health board and my Department to prepare a planning brief for the hospital setting out the functional content of the new hospital, and the drawing up by a design team working from this brief of detailed plans in preparation for building. These steps must be followed logically and in sequence. They cannot, without harm to the project, be telescoped and the interval between the decision to plan and having the plans ready for going to tender is quite long. Therefore, although capital is scarce now, it is wise to get our plans ready for the better times to come.

As regards the Mid-Western Health Board area Deputies will remember that it was not possible to arrive at firm conclusions in relation to the development in the Limerick area. A special sub-committee of Comhairle na nOspidéal had examined the situation but they were not able to make any agreed recommendations. Further studies were necessary to enable a decision to be arrived at—discussions and studies are taking place at the moment and I hope I will be able to put my proposals to the local bodies quite soon.

One of the decisions which was made in respect of the Mid-Western Health Board area was the retention of Nenagh County Hospital with joint staffing arrangements with one or more of the Limerick hospitals. In this regard, discussions have also taken place between officials of my Department, members of the hospital staff, and officials of the health board. I shall be writing soon to the health board on this subject.

In the north-east, the health board have designated Cavan Hospital as their priority. Discussions have been held with officials of the health board on the catchment area for the new hospital and on the number of departments and beds which would be needed to serve the projected population of that catchment area.

In the North Western Health Board area, it was agreed that Letterkenny should be the priority for development. The project team have recently completed their planning brief and the board have submitted it for my approval.

The South Eastern Health Board have recently informed my Department that they had decided on the maternity and paediatric sections of Ardkeen Hospital, Waterford, as the first phase of the development project to be planned. This will involve general decisions on the size and composition of Ardkeen Hospital and I propose that my Department will shortly have discussions in the matter with officers of the health board.

In the Southern Health Board area, the project team for the Tralee Hospital have completed their brief and the design team, working from the planning brief, have been involved for some time in drawing up the detailed plans.

The House will recall that in December I referred to the rather complex situation in Cork. The recommendations of the sub-committee of Comhairle na nOspidéal which had considered the hospital pattern there were not fully agreed to by the various interests concerned. I also indicated that I considered that further discussions with the parties concerned would be necessary before the final pattern of the Cork city development could be determined. These discussions have been held and I shall be in touch with the parties concerned soon.

Discussions have also taken place between officials of my Department, officers of the health board, and members of the staff of Mallow Hospital, which is being retained, regarding the joint staffing of the hospital in association with one or more of the Cork city hospitals. I shall be writing soon to the health board on the subject.

The Western Health Board are to consider which of the two proposed major projects in their area should be the priority—the extension of the maternity unit at Galway Regional Hospital or the development of Castlebar Hospital. In the meantime a project team have been established in respect of Castlebar Hospital. As regards the Midland Health Board area, I am in contact with the board on the choice of a priority between the two hospitals chosen for development.

This, therefore, is the situation at present regarding the implementation of the hospital development plan. Deputies will appreciate that the preliminary preparations for planning are most time consuming having regard to the amount of discussion and study which has to be completed. The progress which has been made to date is reasonably satisfactory and I can assure the House that the further stages of implementation will be pursued. I regard the implementation of the plan as one of my priorities and I would like here and now to reiterate my commitment and that of the Government to the decisions we have taken.

I would remind Deputies of the estimate which I gave in December of the cost involved in implementing the plan. I explained that until detailed evaluation is made it would not be possible to indicate a firm cost but on the basis of tentative estimates gross capital expenditure, at 1975 prices, is likely to be of the order of £65 million—excluding the cost of development in Cork and Limerick cities.

I should now like to refer to the concept of the community hospital which is an integral part of the general hospital development plan. When announcing my decisions on the general hospitals I indicated that following discussions with the health boards, a number of hospitals throughout the country would be classified as community hospitals. There has been a certain amount of misunderstanding as to the precise role of these hospitals. I have, in this House, on various occasions spelled out in some detail the probable functions of a community hospital. Despite this, the part which the community hospital will play in the general hospital services is still not fully appreciated. I would therefore like to give Deputies once more a general outline of the services which will probably be available in these hospitals. The community hospitals will have an important and significant role to play and they should provide the bridge between the specialised services of the general hospitals and the services of the general practitioners. Comhairle na nOspidéal has published a discussion document on the role of the smaller hospitals and copies have been circulated to all Deputies. This document suggests the type and range of services which would be provided in the community hospitals and I intend that this will form the basis for consultation between the health boards and my Department on how each of the designated community hospitals will operate

It could be expected that in most areas community hospitals will have a wide range of consultant out-patient services; and that apart from services at out-patient level such as medical, surgery, obstetrics, gynae-cology and psychiatry, radiology and pathology services would be available for both out-patients and in-patients.

As far as in-patients are concerned the community hospital would make available a range of services which could adequately be provided by local general practitioners working in association with consultants from the general hospital. The benefits which will arise from this arrangement are that the patient will be able to obtain certain treatment in a hospital in his own area and the demand on the highly specialised and expensive services provided by the general hospital will be consequently reduced. It is also envisaged that patients who have been treated in a general hospital and whose course of treatment has been concluded there, can return to the community hospital to convalesce. The community hospital, therefore, has a most important role to play in the provision of general hospital services. I have indicated that consultations would take place between the health boards and my Department to formulate in a detailed way how each of the community hospitals would operate. This consultative process has begun and it will, of course, be necessary to involve other interested parties, including the medical and nursing professions. It is hoped initially to formulate an agreed tentative policy for the provision of services in the hospitals and to apply this on an experimental basis to a small number of selected community hospitals.

I would like to mention some of the major developments which have taken place in the hospital capital programme during the last year.

The largest project in the programme is the 600-bed Cork Regional Hospital to which I have already referred. The main six-storey patient block was "topped-off" in October last and progress towards its completion at the end of 1977 is being maintained.

At St. Vincent's Hospital, Elm Park a new psychiatric unit and a geriatric assessment centre have been completed.

Also completed were: a new maternity unit at Wexford County Hospital; nine new welfare homes for the aged dispersed throughout the country; a new ophthalmic unit at Ardkeen Hospital, Waterford; large-scale schemes of rehabilitation and extensions at St. Laurence's Hospital, St. James's Hospital and the Mater Hospital, Dublin; reconstruction of Linden Convalescent Home, Blackrock, County Dublin; detoxification unit at Jervis Street Hospital, Dublin; a new psychiatric unit and improvements to sanitary annexes at St. Finan's, Killarney.

In addition, a wide range of other major hospital building projects are in progress at present. These include: a psychiatric unit at Letterkenny County Hospital; a new 30-bed district hospital at Donegal; paediatric, psychiatric and laboratory units at Limerick Regional Hospital; provision of new facilities for treatment of cancer at St. Luke's Hospital, Dublin; a new accident department at Jervis Street Hospital, Dublin; a new delivery suite at Airmount Maternity Hospital, Waterford; theatre improvements and other works at the Mater Hospital, Dublin; a new Cheshire Home, Bohola, County Mayo; a new 72-bed unit and other works at St. Ita's, Portrane; acquisition and adaptations of premises at Cloonamahon, County Sligo for the care of the mentally handicapped; a new centre for the care of adult mentally handicapped is nearing completion at Bawnmore, Limerick; new accident and emergency unit at Dr. Steevens's Hospital, Dublin.

These are but a selection of the ongoing new works and improvements at hospitals. In addition to these, a number of other developments are at planning stage. These include: a new pathology laboratory and other improvements at St James's Hospital, Dublin; five welfare homes for the aged; a new maternity unit at Ardkeen Hospital, Waterford; development schemes at Letterkenny and Castlebar County Hospitals.

As the House is aware, new projects for start in the present year have had to be deferred but I am optimistic that this is but a temporary set-back and that in the next year we may be able to resume new starts in our hospital building programme.

Persons eligible for hospital treatment under the Health Act, 1970 may enter an approved private hospital or nursing home and obtain a daily contribution from the health board towards the cost of maintenance. The rates of contribution payable in such cases were increased by 10 per cent as from 1st January, 1976. They now range from £4.40 a day for treatment in private hospitals and homes which have acute treatment facilities to £1.95 a day for geriatric homes. This 10 per cent increase may not have been as much as the proprietors of these homes had wished for, but it is a significant increase at a time of financial difficulties.

There has been some criticism that eligible persons who enter private hospitals and nursing homes have to pay more to obtain treatment in a private hospital than in a private ward of a public hospital. This may well be the case in many instances but, if so, it is simply the result of the way the two hospital systems work and are financed. Public hospitals are non-profit making organisations financed almost entirely from the Exchequer. Many of them are training establishments for doctors and nurses and provide a range of treatment far greater than that obtainable in private hospitals or nursing homes.

Nevertheless, I think we can all recognise that the private hospitals and nursing homes have an important part to play in supplementing the public system. It will be my aim that they will continue to receive reasonable subventions towards the cost of treatment of persons eligible under the Health Acts.

An efficient ambulance service is a necessary adjunct to our hospital services and for this reason it is important that the operation of the ambulance services should be kept under review. Health boards have about 200 ambulances and 50 minibuses. The ambulance men are specially trained for their job by means of a five-week's course in first-aid and resuscitation. All the health board ambulances have radio-telephone equipment with which they can keep in touch with their ambulance control centres.

Though the service has improved greatly within the past decade there is still room for improvement. Improvements are needed especially in the organisation of radio-telephone communications for ambulances. In many areas these radio communications still function on a county basis, with the result that ambulances in one county may not be able to contact the radio control centres in adjoining counties. This needs to be rectified. Short-term and long-term proposals for improvement of the radio-telephone arrangements have recently been received in my Department from each health board. After examination of these proposals by the committee on ambulance services, they will be discussed with officers of the Department of Posts and Telegraphs so that agreed improvement measures can be undertaken.

By these measures it is anticipated that the availability of ambulances for accidents and emergencies will be speeded up, particularly in some rural areas where delays sometimes occur in getting an ambulance to the scene of an accident.

Mental illness continues to be one of the most pressing of our health problems. Psychiatrists and sociologists and others in touch with the problem are divided as to whether its actual incidence is increasing. What is certain is that more people are seeking care for it and that every year the demand on the psychiatric service grows. This year health boards will spend over £36 million on our psychiatric services. But this figure does not include the concealed cost of mental illness in other health services, notably in the family doctor service and in the general hospital service. Indeed if it were possible to identify accurately the impact of mental illness on the demand for health care as a whole there is no doubt that it would be found to be an exceedingly important one.

Because of the seriousness of this problem for the individual and the family, not to mention the financial implications for the State, a Minister for Health must feel obliged to review constantly the strategies being used to tackle it. We are fortunate in having the very comprehensive recommendations of the Commission on Mental Illness to guide us and even though it is now ten years since its report was published most of its views are still valid. Nevertheless, a decade has elapsed and I think we should stand back and look critically at what has been achieved during that period and look also at what needs to be done. Experience may show that our priorities should be different, that the emphasis may need to be shifted to problems that have become more acute in recent times. This is the type of review that I am having undertaken in the White Paper now being prepared in my Department and which I propose publishing later in the year.

In introducing my Estimate for last year I pointed out that the biggest problem facing all those concerned in the provision of residential services for the mentally handicapped is the ever increasing proportion of places in the residential centres which are occupied by adolescents and adults. The latest figures available to me show that this trend is continuing and now almost 50 per cent of the available places are occupied by adolescents and adults. This inevitably shows down the reduction of the waiting lists of children whose parents are anxious to have them received into residential care.

There is, however, a sufficient number of projects at various stages of development or planning to ensure that there should be, within a few years, a substantial improvement in regard to the places available for both adults and children. Unfortunately, like other aspects of the health services, the speed at which these places will become available must be influenced by the financial situation. All I can promise in present circumstances is that the mentally handicapped will continue to have a high priority where I am concerned.

I would emphasise, as I have done on various occasions in the past, that my Department will be basing their approach in regard to new developments on the maximum possible use of community services as opposed to residential care. We shall, in future planning, be considerably assisted by the census of the mentally handicapped carried out last year under the aegis of the Medico-Social Research Board. An analysis of the census has now become available and my Department have established a small group of Department and nonDepartmental persons to examine the results and to estimate our probable requirement of places, both residential and community, for the years ahead. Up to now our planning was based on our estimated needs. Now we have a more accurate picture of the situation and we can plan with greater assurance.

All advanced societies now accept that their obligations towards the individual citizen who is unfortunate enough to have a permanent or long-term physical or mental handicap should be comprehensive. It is not enough to provide treatment, or care in an institution, or a compensatory financial allowance. the handicapped person must also be given every assistance to become as fully integrated in society as possible. Full integration necessarily implies providing him with the training and the opportunity to lead a working life. My Government have accepted this duty as an important part of their social policy and despite the inhibitions of the present financial situation I am glad to report progress in this area during the last year.

All supervisory and training staff in existing voluntary and health board workshops for training handicapped persons have been given an opportunity to undergo a special course devised by the National Rehabilitation Board in association with each other. The aim of the series of courses which have now ended was to improve the training methods of the personnel concerned and the courses secured the recognition and financial support of the European Social Fund. Further courses for other personnel in the rehabilitation field are under consideration.

I am glad to say that, arising from the recommendations of the Working Party on the Training and Employment of the Handicapped, AnCO have found it possible to increase their intake of handicapped trainees and I would like to take this opportunity to acknowledge their efforts in this area. Because of financial constraints it has been possible only to a limited extent to provide assistance for the development of training and additional places in the workshops operated by voluntary bodies and health boards. But I have found it possible to authorise the expansion of the adult and young placement services of the National Rehabilitation Board and this means that some parts of the country now have an improved placement service for their handicapped services.

The board are also pushing ahead with their planning for the future. They have established a number of sub-committees which will, inter alia, recommend standards for the organisation and operation of workshops and explore new training opportunities for the blind. It has been possible to secure the participation on these committees of persons with expert knowledge and valuable experience and I have no doubt that as a result we can look forward during the next few years to better training facilities for all handicapped persons who require them.

In any event if we are to continue to get worth-while assistance for these facilities from the European Social Fund we will have no choice but to improve and develop them. Health boards and voluntary bodies must recognise that European Economic Community policy is directed at upgrading training standards for the handicapped in all Community countries. The grants available from the Social Fund are intended to assist the Progress of that policy and the various bodies concerned in this country must, with the passage of time, expect more stringent criteria to be applied by the Commission in dealing with applications.

In the final analysis the success of any policy aimed at providing employment for handicapped persons will depend on the goodwill of employees and trade unions and the community at large.

A study group which reported to the Minister for Health in 1967 on the child health services recommended the medical screening of all pre-school children at specified ages so as to monitor the extent to which they were developing within the normal range, to detect and keep under review any children who were showing deviation from normal development and to refer for appropriate care any suspected or identified cases of disease or defect. It was envisaged that initially the service would be provided in the cities and towns with populations of 5,000 and over. At a later stage, and in the light of experience gained in the operation of the service, it was intended to extend services to the remainder of the country.

With regard to pre-school examinations it was envisaged that there would be three examinations for pre-school children; one at six months, one at 12 months, and one at 24 months. In terms of total numbers of children eligible, achievements at the six-month examination—which in practice involves an examination carried out when the child is seven to nine months old—must be regarded as satisfactory with the percentage of eligible children examined rising from 66 per cent in 1971 to 79 per cent in 1974. A significant, if not very large, number of children have been examined at 12 months and 24 months representing in 1974 24 per cent and 10 per cent, respectively, of eligible children at the 12-months' and 24-months' examinations.

As regards school examinations, it was envisaged that in addition to annual testing of vision, posture and cleanliness carried out by public health nurses in all national schools, all national school entrants should undergo a comprehensive medical examination when they were approximately one year at school and that a further examination would be undertaken of a limited number of children including, in particular, children between the ages of nine and ten years, selected on the basis of information obtained about them from their parents, teachers, nurses or other interested persons. Other children on observation by the school doctor would also be medically examined. There has been a very satisfactory level of examination of school entrants, but the selective school medical examination is not, as yet, functioning at a satisfactory level. While developments in the past few years in reorganising the general medical services, in the establishment of community care teams, and in the appointment of directors of community care, have to some extent slowed down the pace of development of the school health examination services, the concentration of resources on pre-school development paediatric exams is perhaps the one single factor which has most contributed to this situation.

The public health nurse is a key figure in the delivery of community care services. The last decade has seen a very considerable development of the nursing service and the number of nurses employed has more than doubled in that time. An indication of the rate of expansion may be gauged from the fact that each year approximately 65 new trainees were recruited and given a year's special training in preventive work which they would not have received in the course of their basic general and midwifery training. The public health nurse is frequently the first point of contact between families and the health services; as a locally based nurse she gets to know the families in her area and is available to provide advice and nursing care, ranging from that required by the expectant mother or pre-school children to the sick nursing care of the aged and chronic sick.

A report submitted to me by a working group, which surveyed the workload of public health nurses, was published last July. The report contained a wide range of recommendations and a number of these recommendations are in the course of being implemented. These include better working conditions for public health nurses such as a 40-hour working week and arrangements for limiting week-end duty.

Other recommendations of this report are being considered within the Department with a view to establishing the extent to which they can be implemented, having regard to their nature and to the financial and other resources available. Perhaps I should mention two of these recommendations in particular; one relates to the provision of a full range of public health nursing service to persons in all income groups. At present only a limited number of services are provided by public health nurses for people in the higher income bracket. These include preventive services for pre-school children and children attending national schools and nursing help for mentally handicapped children living at home. The recommendation of the working group would, for example, extend home nursing services to all income groups.

The second recommendation which I would like to mention is the suggested increase in the number of public health nurses. This recommendation arises because of the suggested extension of a full range of nursing services to all income groups and also because the working group considered that a more intensive service should be given by the nurse to the community. The effect of the recommendation would be the recruitment of approximately 300 more public health nurses. As I already indicated approximately 65 nurses have been trained in public health nursing each year for the past decade. This, I feel, allows for a significant expansion especially as the loss through retirement, deaths, and so on is very small. It is more important, I believe, to select a limited number of trainees and thus ensure that the very high standard of public health nurse recruited is maintained than to allow that standard to drop through an extended recruitment scheme.

In the current year the general medical services will cost over £24 million for 1,162,000 persons. The costs have now doubled since 1972-73 when the service was reorganised.

The present scheme has been in operation nationally for just over three-and-a-half years and it is possible to make some general comments on the manner in which it is operating. In general the scheme is achieving the targets set for it when it was reorganised. The main aim was to provide a choice of doctor, as far as possible, to eligible persons and to enable them to obtain the necessary drugs and medicines from community pharmacists.

There are now about 1,300 doctors participating in the scheme and medicines are dispensed by about 1,200 pharmacists. The medical needs of eligible persons are met, therefore, by almost twice the number of doctors who operated under the dispensary system and the introduction of the community pharmacist into the service has greatly increased the number of outlets from which to obtain medicines. These changes, which have clearly improved the availability of services, have been welcomed by patients generally.

While the service has in general improved as a result of these changes there are aspects of it which give cause for concern. In particular I would draw attention to the very noticeable increase in the cost of providing drugs and medicines. It has risen from £8 million in 1973 to £10 million in 1974 and last year reached £15 million. Such increases are disproportionate to the increase in the number of persons covered by the scheme.

The increase in the cost of drugs has been such that in October of last year I established a working party to examine prescribing patterns in the general medical service, to consider the extent to which there might be over-prescribing or the prescribing of needlessly expensive medicines, to consider the question of prescribing with due regard to economy and to make recommendations to me on these matters. The working party was composed of officers of my Department, members of medical and pharmaceutical organisations and the drug industry. They had access to the statistical information about prescribing under the scheme and information from some other countries facing similar problems.

In setting up the working party I emphasised to them my concern not alone with the cost, serious though this is, but also the undesirable if not dangerous aspects of excessive prescribing. I have within the past few days received their report and I will have it examined as a matter of urgency. I shall consult also, on an urgent basis, with the other interests involved to establish quickly the extent to which the recommendations of the report can be implemented.

In the meantime there are certain aspects of the service which it is generally accepted, might be improved. The General Medical Services (Payments) Board have written to doctors seeking their co-operation in reducing the escalating costs of drugs. I am informed that the reaction to this approach has in general been favourable and some useful suggestions were offered. I am hopeful that doctors will critically examine their prescribing habits in the months to come.

There is also considerable support for the view that the scheme could be improved to the advantage of all if patients could be educated in making better use of the service. What I have in mind is that where patients can they should attend at the doctor's surgery rather than request a house call, but if a house call is necessary they should notify the doctor early in the day, say before 10 o'clock wherever possible. This would enable the doctor to plan his house calls better and thereby attend the patient more quickly. Advice on the proper use of medicine would also be helpful but special care would be necessary in the way it is presented. Of course any educational programme must be designed in such a way that it will achieve its results without inducing people to defer seeking timely advice from their doctor.

These are matters to which consideration must be given. I draw attention to them because they are shortcomings capable of being remedied without disadvantage to anyone and whose resolution would considerably improve the scheme.

During the past year I made further regulations extending controls over the manufacture and marketing of medicinal products in harmony with directives adopted by the EEC. The directives to which the regulations relate are an attempt by the EEC to further harmonise the licensing systems of the member states towards the ultimate goal of a common market in medicines. They do not of themselves confer a right of access of any product to the market of a member state but are merely intended as another step in that direction.

The principal effect of the new regulations is to extend a system of licensing to proprietary medicines which were already on the market on the 1st October, 1974—the date from which no new proprietary medicine could be put on the Irish market without a licence. These products will be licensed in a phased scheme which will be completed in 1983, beginning with anti-infectives, tranquillisers, hypnotics and sedatives which, with effect from the 1st April, 1977, may not be on the market here unless they are authorised by the Minister for Health. In the implementation of the schemes my Department are advised by the National Drugs Advisory Board who have also been given charge of the supervision of the observance of conditions imposed in licences issued upon their recommendation.

It is appropriate that I should pay a special tribute to the dedication and competence of the National Drugs Advisory Board in the discharge of their task of monitoring the quality, safety and efficacy of drugs and medicines available to the public in Ireland. For almost a decade now the members of this multi-disciplinary board have voluntarily given unstintingly of their time to serve the best interests of the community and we are all greatly indebted to them for this.

Also in the field of medicines control, I have recently made regulations amending the Medical Preparations (Control of Sale) Regulations, 1966, so as to extend the list of medicinal preparation which may be sold only on prescription. The preparations added include certain preparations contained in aerosols for the relief of asthma, corticosteroid compounds for external use and preparations containing phenacetin. The substances in question have been shown to present certain hazards if taken without medical supervision and on the basis of the advice given to me by the National Drugs Advisory Board it was clear that the public should be afforded this additional protection. I think I should report to the House that, while the number of new cases of tuberculosis showed a continuing decline up to 1972, when the figure was 1,147, it has since shown a small but disturbing increase. The figure for 1973 was 1,182 and for 1974 it was 1,204. This means that pockets of infection still remain in parts of the country.

Vigorous methods are being operated by the public health staff of the health boards to trace these sources of infection but the co-operation of the public in availing of the facilities offered for diagnosing and treating TB is essential. Having reduced the number of new cases of TB from 6,800 in 1952 to 1,200 in 1974, it would be a pity if we now became complacent about this disease.

My medical advisers are watching the situation regarding vaccination of children against diphtheria, tetanus, pertussis and poliomyelitis. The success of vaccination against diphtheria and polio is incontrovertible: we have had no notification of diphtheria in the past five years and only two cases of polio in the same period. In the case of vaccination against pertussis—whooping cough—which is normally given with diphtheria and tetanus vaccination to children at about six months of age the numbers availing themselves of this "3-in-1" vaccination have been falling off and this fact is, of course, a cause of concern.

The most recent figures available show an acceptance rate of 35 per cent for Dublin for 1975 as compared with a 70 per cent target figure which is accepted as providing a satisfactory level of immunity.

I can understand that parents may have misgivings about this vaccination when they read of cases of brain-damage to children alleged to have been caused by the pertussis element in the vaccine but these parents should also consider that there is no substantiated medical evidence to prove these allegations. The medical profession are well aware of the known contra-indications to vaccination and where no such contra-indications exist vaccination is still recommended as an extremely effective tool against whooping cough and the other diseases I have mentioned.

In keeping with the Government's commitment to ensure that maintenance allowances should retain their purchasing power, the maximum rates of disabled persons maintenance allowances and infectious diseases maintenance allowances were increased by 5 per cent in October last and by a further 10 per cent in April this year. In addition allowances payable under the blind welfare schemes and those payable to thalidomide children were increased this year to keep them in line with the general level of changes in the other allowances.

The overall effect of these improvements may be seen from a comparison of the maximum rates now payable as compared with the corresponding rates before April, 1975. For example, the disabled persons allowance has increased from £7 to £9.85 a week. For married couples the existing allowance under the infectious diseases maintenance allowances' scheme is £18.20 as compared with £13.00, while under the blind welfare scheme, a blind married couple can now receive a supplement to their joint pensions of £7.10 a week as compared with £5 before April, 1975.

It is estimated that additional expenditure in the order of £1 million will result from these increases in the period April to December, 1976. Of course, special additional funds will be made available to the health boards to meet this expenditure.

It is now almost a year since the reconstituted National Social Service Council came into office. As part of the reconstitution, voluntary organisations engaged in the provision of social services were given direct representation on the council. I am glad to say that this arrangement has worked very satisfactorily and that the council provides a very good forum for the discussion of both policy and operational issues affecting statutory and voluntary organisations in the provision of personal social services.

The council has made good progress in the establishment of community information centres. At this stage, a total of 45 have been established and it is hoped that the number will be about 60 by the end of this year. The council has been able to provide improved support services to the centres and the material which it produces is of considerable value to many other bodies, both statutory and voluntary.

The council has worked very closely with the National Committee on Pilot Schemes to Combat Poverty particularly in relation to the projects dealing with welfare rights and social service councils. Areas for co-operation and sharing of services between the council and the committee are being explored and it is likely that the council can be of particular value to the committee in the provision of information and information systems.

The council has arranged a conference to be held in Limerick at the end of May. At this conference, the work of social service councils from 1972 to date will be reviewed and both the policy and operational implications of statutory and voluntary co-operation in the provision of community services will be considered.

This question of how the statutory agencies and the voluntary organisations can best work together to provide community welfare services continues to be a matter of deep interest to the council and, indeed, to my Department. I think the time has come when it is necessary for my Department to take an initiative in developing and agreeing a policy document on the scope and structure of personal and community welfare services under health boards and the respective roles and relationships of the statutory agencies and voluntary organisations in the planning and provision of these services. Work has already commenced on the preparation of this document and it is hoped to circulate an outline draft to the health boards, the council and the various other interests concerned in the very near future. I would hope that the debate on this document would be objective and challenging and that at the end of the day there would be a satisfactory measure of commitment to the principles and practices contained in it. Because of its importance and the number of interests that must be consulted, it will necessarily take some time before it can be agreed and promulgated as a policy document.

In September, 1975, the task force on child care services submitted an interim report to me. This was published and circulated to Deputies on 18th November, 1975. The task force submitted an interim report because it considered that certain steps should be taken as quickly as possible to provide for the more urgent needs of some of the children with which it is concerned. The recommendations made in the interim report were particularly concerned with the needs of disturbed and homeless children.

Although it was an interim report, there are some very significant recommendations made in it and many of the recommendations are closely interconnected. Their full implementation will require considerable resources of finance and trained personnel which, in the current situation, cannot be quickly made available. Nevertheless, it has been possible, despite the obvious difficulties, to make some progress.

Consultations have taken place with the agencies who will be primarily concerned with implementation of the recommendations, notably the Department of Education and the Eastern Health Board.

Through the initiative of the Dublin itinerant settlement committee, and the support of the Department of Local Government and the Eastern Health Board, arrangements have been made for the provision of accommodation at Newtownmountkennedy for 17 travelling children in need of residential care. This is an admirable undertaking which deserves our full support. The Eastern Health Board have recently had discussions with representatives of the committee regarding the future arrangements for the management of the accommodation and the continued support of the children during this year. I have every reason to believe that mutually satisfactory arrangements will emerge from these discussions. I have asked the Eastern Health Board to examine urgently the feasibility of adapting an existing premises for use as a residential centre for severely disturbed boys and girls and discussions on this matter are continuing.

The Eastern Health Board are at present conducting a local survey to confirm the extent of the need for accommodation for homeless boys and young vagrants. Meetings will then be arranged with the agencies concerned to examine the extent to which existing accommodation can best be used to solve the problem and to consider the provision of such additional accommodation as may be required.

I would, naturally, like to be able to report greater progress on the implementation of the recommendations made by the task force. However, some progress can be made by fully utilising existing facilities and I would hope to give a high priority in the allocation of any funds that may become available during the next year to the implementation of the recommendations which require additional resources.

We have continued to make progress in the last 12 months in relation to the development of community-care teams, and in particular in relation to the appointment of directors of community care and medical officers of health.

There is now a wide acceptance of the concept of delivering services, outside the hospital programmes, through community care teams representative of the different disciplines involved in community care. The structure and boundaries of the community care areas have been worked out in detail and agreed with the health boards. Conditions of appointment of the directors have been agreed generally with the boards and with the medical organisations; in a number of areas, existing permanent chief medical officers have been appointed as directors of community care and I am hopeful that the position in relation to the appointment of some other chief medical officers will be resolved soon. Eight further posts were referred to the Local Appointments Commission last year and are currently in the process of being filled and discussions have recently been held to resolve the special problems arising in the Dublin area.

There are of course a number of problems which must yet be tackled before community care services can function with maximum efficiency. These problems will include the establishment and grading of a medical structure below the director level, and the provision of proper training and support for the director and the members of his team. Some of these problems have been considered by a working group on the public health medical services, who recently presented their final report to me. Given the goodwill which exists within the service, I believe that these problems will not present insurmountable difficulties.

At a seminar held in Waterford last May, in which the health services were reviewed by widely based working parties, consisting of officers and members of health boards and officers of the Department as well as outside specialists in various aspects of health care, a specific recommendation was made by the group which considered the community services to the effect that more resources must be allocated to those particular services. The recommendation concluded that the major proportion of developmental funds, capital and revenue, that are available to the health services should be channelled into the community care services. I would like to say at this stage that I regard the development of community care services as an area of very high priority. I say this for two main reasons. Firstly, I believe that in the generality of cases money spent on preventive and curative work in the community gives an excellent return in obviating expensive hospital care. Secondly, and at least as important, I believe that an effective community care programme will significantly improve the general health of the community and thus greatly reduce the incidence of certain avoidable diseases and defects.

I am glad to be able to report that, despite the difficult financial situation, I have found it possible to make a significantly increased allocation available to the Health Education Bureau. The bureau has a budget of £300,000 in the current year, as compared with £185,000 in 1975. This reflects the importance which I attach to this activity and the hopes which I have that it can produce positive and continuing results in the area of preventive health.

The bureau has consolidated and extended much of the work which was initiated under the aegis of my Department. In the educational field a number of significant developments have taken place. Pilot projects on health education based on post primary schools have been initiated in north east Dublin, in Monaghan, Cork and Ballinasloe. The objective of these projects is to introduce the whole concept of health education into the activities of the school.

The bureau is developing resources which can be made available to teachers when conducting health education in the schools. These resources include films, tapes and teaching kits, and are mainly geared for post primary schools, although some material for primary schools is also being developed. Progress has been made in injecting health education into the activities of educational authorities other than schools, including An Bórd Altranais and the National College for Physical Education. Efforts in this area will be continued during the coming year. The anti-smoking campaign was continued and an extra dimension was added through the introduction of large posters on billboards throughout the country. The anti-alcoholism campaign has continued as in previous years and later this year there will be a renewed concentration on this subject, and the subject of excessive drinking. It was a matter of considerable satisfaction to the bureau and to me that during the year the award for the best made and most effective commercial film went to the bureau on foot of one of the films produced for the alcoholism campaign.

In the months ahead a physical activity campaign, aimed at the population at large, will be initiated. This is something which I have been very anxious to see initiated and I am glad that the bureau has found it possible to make a start in this year. It is also intended to extend the objectives of the anti-smoking campaign by seeking to wean smokers off cigarettes or to persuade them to reduce the number which they smoke.

Work will continue on the development of coaching charts in association with the various sporting organisations.

The Health Education Bureau has made a very good start on the work which I have asked it to undertake. I know that they are most anxious to devote increased attention to research and to broaden the scope of their activities to areas of health education which have not previously been undertaken in this country. I look forward with interest to the initiatives which I am sure they will propose within the coming year.

The Medico-Social Research Board have developed an extensive programme of information collection and research in the field of epidemiology.

The work of this board is particularly important because it is concerned largely with health and social problems which have elements in them which are peculiar to Ireland and which are not therefore the subject of research in other countries.

The board's major current project— the hospitals in-patient inquiry—is designed to be a comprehensive source of information about the operation of our hospitals which will be invaluable for both research and administrative purposes. Even though all hospitals are not yet taking part in the project, a large amount of useful information is already becoming available.

The board continue to devote a large part of their resources to studies relating to the more vulnerable sections of the community—the aged, the mentally ill and the mentally handicapped. They have also undertaken studies on alcoholism, drug-taking and on suicide.

Some of the board's work is carried out in association with major international organisations, particularly the World Health Organisation and the EEC. This work includes studies on heart disease and strokes and on the effects of air pollution on the health of children.

Turning to personnel matters, the quality of any health service is largely dependent on the skills and commitment of the people which it employs. The service is, by its nature, a uniquely personal one. Despite other technological advances which have taken place, it remains essentially a service of person-to-person contact. This is naturally reflected in the numbers of people working in our health services which at present number about 46,000 in nearly 300 different grades. Annual expenditure on staff is now in the region of £156 million, representing about 60 per cent of current public expenditure on the services. This represents a very considerable investment both in terms of money and in manpower and highlights the importance of effective personnel policy and management in relation to the satisfactory functions of the service. There is, I believe, a growing realisation of this fact at both national and local level, and I need not stress that in times of difficulty and restraint it is of singular importance that staff are fully and properly utilised. In this regard, if due attention is paid to staff training and development as well as recruitment and manpower planning, the service itself as well as the people concerned will benefit.

It is only to be expected, of course, that the general economic climate brings in its wake tensions and frustrations over and above the normal. For that reason I think we should all be grateful that the past year has been relatively trouble-free and that, by and large, confrontation and dispute situations have been avoided. For this the staffs themselves must take the greatest credit and are to be congratulated for the restraint and sense of responsibility which they have demonstrated. For my own part I will continue in my endeavours to ensure that good staff relations are maintained and fostered. I would hope also that the revised and expanded conciliation and arbitration scheme for health board and local authority staffs which was recently agreed will facilitate this process. This factor combined with the extension of the membership of the Local Government Staff Negotiations Board to include officers of the Departments of Health and Local Government should help to improve and rationalise the approach to negotiations to the benefit of staff and management alike.

Legislation of the European Communities, commonly referred to as the doctors' directives, was adopted by the Council of the Communities on the 16th June, 1975. There are two directives and both are scheduled to come into effect in all the member states by the 19th December, 1976.

The directives aim at making provision, firstly, for the recognition by each member state of the medical qualifications, both at general and specialist levels, awarded in the other member states; secondly, for giving effect to the right, contained in the Treaty of Rome, of free movement of doctors within the Community for nationals of the member states and, thirdly, for setting and maintaining specified minimum standards of medical training in all the member states.

To assist in the implementation of the provisions of the directives, the council decided on the 16th June, 1975, to set up two committees. They are the advisory committee on medical training and the committee of senior officials on public health. These two committees have now been established. The latter consists of officials belonging to the health ministries of the member states. The former contains representatives of the practising profession of the medical faculties of the universities and of the national registration bodies.

Arising from the EEC doctors' directives, it will be necessary to adapt our domestic legislation before the 19th December, 1976, to meet the requirements of the directives. This could be done by regulations under the European Communities Act, 1972. I was aware, however, that there were other aspects of the statutory regulations of the profession which were pending for some time. Some of these were matters which the profession itself had been pressing; others had come to notice from different sources.

I, therefore, last July decided to set up a committee and asked it to examine and report to me on the changes necessary in this area generally. In addition to representatives from my Department, the committee had representatives from the medical schools, the Royal College of Surgeons in Ireland, the Royal College of Physicians of Ireland, the Medical Registration Council, Comhairle na nOspidéal, the Council for Postgraduate Medical and Dental Education and Training and the Irish Medical Association with the Medical Union. The committee submitted an unanimous report to me last December recommending some important changes in the law regulating the profession in addition to the changes required solely to meet the requirements of the EEC directives.

The recommendations are that there should be a new and more broadly based Medical Council, more representative of the practising profession, to replace the Medical Registration Council and which would have functions in relation to postgraduate as well as undergraduate education and training. The new council would also have functions in relation to doctors' fitness to practice by reason of illness or infirmity or other reasons; functions which would be capable of being used in a more flexible, and humane manner than those available to the existing council.

The recommendations made by the committee are being examined. Prima facie, I can say that the changes recommended appear sound and they are, in general, acceptable to me. I would hope to bring legislation before the House in the autumn. Before leaving this subject I would like to place on record my appreciation of the contributions made by the various interests represented on the committee which produced these recommendations.

Deputies will already be aware of the circumstances leading to the setting up of the review body on consultants' remuneration in the summer of 1974. It resulted from the breaking down of negotiations which had been in progress for some months with the medical organisations about a new uniform type of contract for medical consultants in the health board hospitals and in the public voluntary hospitals in the light of the Government's decision to abolish income and other limits for eligibility for hospital services.

The terms of reference given to the review body were to examine and report on the systems and rates of payment and conditions of employment of consultants in hospitals providing services under the Health Act, 1970, which would be appropriate in the context of the abolition of income and other limits related to eligibility. The members of the body are Mr. W. Finlay, Governor Designate of the Bank of Ireland, Mr. J. Ivers, Secretary General of the Incorporated Law Society and Mr. M. Cosgrave, Deputy Chairman of the Labour Court. I am informed that the body has carried out extensive examinations of the matter before it and expects to be in a position to report to me in a matter of months.

In September, 1972, the then Minister for Health requested Comhairle na nOspidéal to suggest to him a common selection procedure for consultants' appointments which would be generally acceptable to the interests concerned and which would apply in the case of all public hospitals providing services under the Health Acts and to indicate in broad outline the machinery for the implementation of such a selection procedure. The aim is to integrate into a single system of selection two existing procedures, one, in the case of the health board hospitals, based on the Local Appointments Commission and the other, in the case of the voluntary hospitals, based on individual and mostly unco-ordinated procedures.

In their report submitted to me in March, 1974, the comhairle set out the procedure and the machinery for a new selection system as requested. The comhairle stated that they were satisfied, following the consultations which they had carried out, that their proposals were generally acceptable to the majority of the interests concerned. I am grateful to the comhairle for the expert manner in which they tackled this issue. Their report is still under examination in my Department. Deputies will appreciate that the problems involved in marrying two very different systems of selection into one uniform system acceptable to all interests are quite formidable. However, I hope to move to a resolution of this issue in the present year.

In August of last year I established a working party to examine and report to me on the various issues affecting the role of the general nurse in this country. The membership of the working party is widely representative of all the various bodies and staff organisations concerned with this area of the health services. The task which confronts the group is a formidable one, but I am satisfied that the group of people appointed are well equipped to undertake the work. The nursing organisations have long felt the need for an examination of this kind into the whole question of the role of the nurse and the education training and structures necessary for the fulfilment of that role. The terms of reference which I have given the working party are sufficiently wide to enable them to explore all aspects of the problems involved and I am sure the outcome of the exercise will be to the benefit of the nursing services and at the same time improve the job satisfaction for the nurse herself. The nursing services are a most vital and important sector of our health services and we cannot afford to ignore any measures which will help to improve the efficiency and effectiveness of these services. I look forward to receiving the views and recommendations of the working party.

A working party with representatives from all the member states was set up in February, 1975, to examine the position of general trained nurses on the same basis and with the same objectives as in the case of the directives on doctors. My Department and An Bórd Altranais represented this country on the working party.

They have now completed their examinations of the subject and a small number of unresolved issues, none of them originating in this country, have been referred for decision to the Committee of Permanent Representatives of the EEC.

I will conclude by referring to some points on the organisation of the services and their administrative structure.

The first term of office of Comhairle na nOspidéal ended on 31st December last. Following wide-ranging consultation with the various organisations and interests concerned, the 23 members who will hold office for a three-year period from 1st January, 1976, were appointed.

The comhairle, since their establishment in 1972, have carried out their primary function of regulating the numbers and types of consultant appointments in hospitals most effectively. They have also played a significant role in the field of hospital services generally. They made a major contribution to the formulation of the national hospital development plan by preparing and submitting reports on various aspects of the development of our hospital services, including the pattern of major hospital developments, the future role of the smaller hospitals and manpower requirements. As I have said earlier, proposals for a common selection procedure for appointments of consultants to hospitals were prepared. They also have prepared valuable reference documents on specific services in the hospital field.

I must express my appreciation of the great value of the work done by the comhairle. The members have contributed greatly to plans for the health services. I thank them, and particularly the chairman, Professor Basil Chubb, for the work they have done and are doing.

I referred recently in this House to the work being done by the organisation unit of my Department. I mentioned the work undertaken with health boards to improve their financial control and budgetary arrangements to ensure that money was spent in the best direction and with the best results, and the pilot studies undertaken in St. Finbarr's Hospital, Cork, and the Mater Hospital, Dublin, regarding the steps necessary to improve their administration systems. With limited resources the overall approach to management services and value improvement has therefore been to select a number of key areas which are broadly representative of situations which will be encountered throughout the health services and to develop and test solutions in these chosen sites which can to a large extent be effectively transplanted to other areas of the service. At the same time emphasis has been placed on the need to monitor developments abroad and to utilise to the full approaches which have been successfully tested elsewhere and are likely to be suitable to our needs.

I also indicated that to speed-up efficient improvements in the field of administration in the health services I would strengthen the organisation unit of the Department as well as the planning unit. I cannot overstress the importance of effective management services. The need to develop good information, accounting and analytical systems to enable planning and review functions to be carried out efficiently is self-evident.

The organisation and provision of computer services, where this is seen to be feasible and economical, is also part of the management services remit. The major effort in this field is being devoted to consolidation of the facilities which have already been provided. Planning for the future expansion of facilities is not being neglected however and a work programme incorporating a number of key developments has been agreed with the users of the computer facilities.

When replying to the debate on the Second Stage of the Health Contributions Bill on 30th March I spoke on suggestions which had been made during that debate that there should be an examination of the health board system. What I said is recorded in columns 511-513 of the Dáil Official Report for that day.

I gave my own tentative views in relation to the need for an examination of the system and of possible methods for conducting the examination with some of the advantages and disadvantages of each. I would propose to discuss shortly with the Government the question of setting up the machinery for this examination. However my statement in the debate on the Health Contributions Bill was made at the end of that debate. Other Deputies had not the opportunity to comment on what I had said. Therefore, before asking the Government to take a definitive decision, I would welcome contributions during the present debate from Deputies on the options which I mentioned.

While I do not think it is necessary to repeat in full what I said in the earlier debate, I would remind the House that, in my view, the options seem to rest between a simple all-party Committee of the House and some body which would have representatives of all parties and outsiders involved in the practical administration of the services, including of course the professions and the trade union interests.

I would ask Deputies to read the report of what I said earlier and let me have their views on the options and ideas which I then mentioned.

The situation that prevails throughout the health service today as we deal with this Estimate for the Department of Health is one of confusion, disorder and hopelessness. It is many decades since Dáil Éireann has been confronted with such an administrative debacle in any Government service. The simple fact is that the sum of money being provided by the Minister and the Government in this Estimate to pay the cost of running our health services this year is inadequate. All the agonising throughout the country, all the disquiet, the complaints, the frustration, the recrimination, stem from this inescapable, basic fact.

I do not mean "inadequate" in any descriptive, parliamentary debating sense. I mean it in its full literal sense. The money provided by the Minister in this Estimate falls measurably short of actual requirements. On this side of the House we have spent a considerable amount of time and effort directing attention to the situation, because it is our parliamentary duty to do so. We know from the membership of our party what the position is. Our members serve on health boards. They are present at committee meetings when programme managers and executive officers outline what is the actual situation. Therefore, we are fully conscious of what the reality is this year in regard to the administration and financing of the national health service.

We are not doing this and we have not done it to harass the Minister, nor at any time have we shown any wish to harass him. We are not anxious to play politics with health. We are simply directing attention to this matter because it is our democratic duty to do it. The fact is that as we have indicated our health services in every area, in every institution, face fundamental disruption this year unless some action is taken by the Minister to deal with the situation.

We have incontrovertible evidence that that is so. I do not wish to spend any time this morning going over the dismal litany again. I think we have illustrated clearly to the House what the situation is. We have shown that in the case of the health boards the allocations made are inadequate and will not permit the boards to provide the necessary level of services. There is no way financially whereby with the allocations made any health board will be able to maintain existing services at a reasonable level throughout 1976.

The most crucial area is, of course, the Eastern Health Board. I want to repeat that, despite the masquerade, the charade that has been gone through by the officials of the Minister's Department and the executive branch of the Eastern Health Board, the deficit is there still and the cut-backs are in operation. They are going to result in considerable hardship on a widespread scale. They are going to result in deprivation and inconvenience. It can be legitimately maintained also that the financial situation of the health boards is going to result in a lowering of the level of medical attention given to the general public.

The same situation is repeated in regard to the hospitals. Again, from our participation as public representatives in the membership of the hospital boards and the management of hospital institutions, we know that the hospitals will not be able to continue with the budgets they have been given to provide a reasonable level of service—and I include medical attention when I say a reasonable level of service—for all of this year. I know of one hospital in the city of Dublin where the staff situation has become such that patients are not receiving the nursing attention they require. I have direct evidence that patients being brought forward for operations are not receiving the level of medical and nursing attention prior to operation that they should be receiving.

These are the realities of the situation, and I return to this matter this morning in discussing this Estimate because I want again to say to the Minister that he must face up to realities, that he cannot much longer maintain this stance, that the allocations made are irrevocable and that there is no further money available under any circumstances. In particular the situation in the major hospitals is serious and acute, and it is impossible for any of us at this stage to measure what the serious outcome of the present inadequate budgets may be.

In discussing this health Estimate, of course, this year, we are only laterally touching on health matters. The reality with regard to this Estimate is that we are being brought face to face in a concrete way with the end product of this Government's mismanagement of the finances of the country. It was right for us, as we have done on many occasions, to talk about the mismanagement of the nation's finances, to accuse the Government of mismanaging those finances in a most serious and fundamental way. To some extent, perhaps, that might seem to many to have been an academic political exercise, but in this Estimate we are confronted with the reality of that mismanagement. We are brought face to face with the situation where a Government, because of its failure adequately to manage our economy and our financial resources, cannot provide in this year a sufficient amount of money to provide for our basic health services.

We want the public, the doctors, and the patients to know that this is the situation. Perhaps more important, we want the Government to know that this is the situation. I believe that there is not a realisation in the Government of the reality. I do not know what efforts the Minister for Health has made to bring the matter to the urgent and critical attention of the Government. For all I know, the Minister may be honestly and assiduously discharging his responsibility in this respect and finds himself met by a stone wall by colleagues who have other priorities. I should like to think that that is so. Therefore, if there is anything we can do in this House to underline the urgency of the case and in that way assist the Minister in dealing with his Government colleagues then we should do it.

It is difficult to grasp the Government's attitude in this regard. It is difficult to see why the Estimate for the Department has been so savagely attacked in this year's budget because it has been more harshly dealt with, more fundamentally emasculated than the Estimate for any other Government Department.

This Government purport to have a great public conscience. They have always paraded themselves as a Government committed to social welfare. If they are such a Government and if they have this commitment they continually talk about, why then, when faced with the stark results of the mismanagement of our finances, did they turn on health in this savage way? Were there not other areas which could have been more harshly dealt with? Government Ministers make speeches, parade their high-minded principles, give public displays of their conscience and it is incomprehensible why they have permitted the financial situation, serious though it is, to have this particularly dire effect on our health services.

It is important that this House should understand and clearly state what the position is; we should express to the Government our view that if there is a difficult budgetary situation, a financial crisis resulting from three years' mismanagement, then the last thing we want to see attacked in an effort to deal with that situation are the health services.

We believe that no other Government service should demand a higher priority. It is the hallmark of any enlightened civilised community that it looks after the feeble, the disabled and the sick. It is the view of the Opposition that even now at this late stage the Government should recast its budgetary disposition in such a way as to make somewhere in the region of £10 million to £15 million extra available for the health services. There is no other way in which the general public can be provided with a reasonable standard of health services during 1976.

How are we to try to grapple with this situation that confronts us all? I believe there is only one way to manage health services in a modern community. Firstly, one must try to assess, as realistically as possible in the particular circumstances of the community and in the light of conditions, what level of service is needed. Only in that way, by directly relating the level of the services to the resources available, can one proceed in any sort of logical fashion to formulate and administer a health service. At the moment the cost of the health services is approximately £250 million. It is not so long ago since the interest alone on that figure would have met the entire cost of the health services. It is legitimate at this stage to ask ourselves where are we going. If it is £250 million now will it be £500 million in two or three years' time.

Our hospital structures are on the point of collapse. I suggest seriously that there is no longer any reality in the Minister's hospital development plan. It is very nice for the Minister to talk about his hospital development plan and to outline steps, processes and developments but there is no reality in it; there is no hope whatsoever that, with the financial situation the Minister faces, he can move in any positive way towards any implementation of that development plan. The situation in the administration of the health services this year is full of all sorts of absurdities and anomalies. We have pointed out, for instance, that in different parts of the country there are homes and institutions which have been built but cannot be opened because money cannot be provided to operate them.

I should like to make it clear that we do not interpret it as our duty to stand on the sideline and constantly complain about the state of the health services or merely point out the failures of the Minister and his Department and the inadequacy of the resources being provided. We had to point out that the Government made a mess of the financial situation this year. It was our duty to do that and we spent a fair amount of time doing it, but we are not just going to keep on along that line. It was necessary to do that because the situation is critical and we had an obligation to direct attention to the fundamental seriousness of the situation. We will continue to monitor the situation as it develops, to watch how things work out as the year unfolds and to press the Minister to make the additional moneys necessary available.

But in this debate we are going to concern ourselves with trying to see what can be done in this situation. We will see if there is anything constructive we can do or say. I believe each one of us has a responsibility to do what he can, the Government, the Opposition, doctors, nurses, patients and trade unions. We will have placed upon us at this time a very serious and onerous responsibility to make our own particular contribution to the serious situation into which our health services have been allowed to drift. I am afraid that the Minister's Estimate speech was very depressing. It was simply a recital of events and happenings, bodies and organisations. I do not think that even the Minister's most fervent admirer could suggest that there was any attempt in his speech to look forward, to try to outline some philosophy for the future. There was no attempt to try to reach out into that future and plot some sort of long-term course and, in doing that, to try to grapple with the fundamental underlying realities of the situation. He made no attempt to look at the long-term developments and see how they can be directed or, if possible, controlled.

There is nothing more puerile than for Ministers of the Government this year to be making speeches boasting about the amount of money they are spending on certain Government services. We had an example from the Minister for Education recently when he was being attacked by teachers for the various failures in his administration. He threw out figures of millions of pounds which he said were being spent on education. They are, however, meaningless. Firstly, they are meaningless because they are coming out of borrowed moneys. There is such a deficit on the budget that no Minister can claim credit for any expenditure. In my view one can only claim credit for public expenditure when one is making that expenditure available out of a balanced budget. But if one is spending money which is being borrowed from the future one should be defensive about it. It is puerile, futile and absurd, to be claiming credit for expenditure of any sum of money in present circumstances. It is particularly so in the case of the health services because, at present, a Minister for Health should regard the rising cost of health services as a black mark against him. We know that the cost of our health services is escalating. It would be perfectly legitimate for the Minister to point to these increasing amounts of expenditure if, side by side with the increases, improvements were taking place.

I was very impressed with what Deputy O'Connell said when we were talking about the Bill to increase the health contributions. He gave it as his opinion, and he is a person in a position to know, perhaps, more than anybody else in this House, that the increasing expenditure was not being matched by improved services. That is a very serious situation. If we have escalating costs without better benefits and better services for the people, then we must look at the situation in depth.

I hope that Deputy O'Connell will again talk on this Estimate about his knowledge and experience in this regard. Apart from the general financial background to the administration of the Government services this year it is blatant for the Minister to point out and claim credit for increased expenditure on the health services, if at the same time, as we suspect, the quality of these services is disimproving. The Minister should seek in the administration of the Department of Health, to get better value for money and not only to be able to say "I am spending £x million". He should be able to show in return for increased expenditure that there are new benefits and improved services. A Minister could actually be commended if he spent less money on health and got better value for it. That is the sort of approach that should be taken in this whole area. Instead of seeking to improve the services, the structures and the administration, we are left with piecemeal initiatives and ad hoc extensions—an unplanned erratic sort of development. That is the way our health services are administered today. In response to pressure, political or otherwise, the Minister embarks on some new unplanned initiative, and announced it with a flourish of trumpets without the proper consultation, without any assessment as to whether it is feasible or as to whether or not the facilities are there to cope with the new development.

We are not anxious on these benches to make political capital out of the present situation. It might seem that we have sought to do that, but I would maintain honestly, that so far as we directed attention to the present situation, it was because attention needed to be directed there. The situation is far too grave to make political issues out of health policies. We should sit down together and determine how limited resources can be directed to the best advantage of the greatest number of people, not only now or in the foreseeable future but as far ahead as men of intelligence and goodwill can plan. That is what is demanded, and where our duty lies. We should combine all our intelligence, experience and knowledge in making some sort of fundamental long-term plan for the future. In that connection I welcome and endorse the recent call by the president of the Irish Medical Association for the creation of an all-party committee to study and report on the best means of providing health care for our people. I fully support that call in principle. When I first heard the reports of the address given by the distinguished president, I was somewhat disconcerted, because into his speech there crept the old cliché of taking health out of politics. Subsequently from what the president said it was quite clear that what he really meant was that we should seek to take health policy out of the particular cockpit of party-politics, not out of politics. Health is a community service and, therefore, must always be the subject of political processes.

I agree that it would be desirable if we could have some procedure whereby the setting of targets and the charting of policies, even in broad outline, could be achieved in some non-party political way. This idea has also been put forward trenchantly by Deputy O'Connell. An all-party committee could be established which would study and report on all financial administrative policies, it could report on the general state of health policy or we could establish committees for more limited purposes. Whatever machinery is decided upon, or whatever task such a committee might be given, it can be accepted that it will be favourably considered from this side of the House. We would be very pleased to participate in the work of any such committee. It would be essential that such a committee would also receive the fullest support from the various outside organisations and bodies—the professional bodies, the trade unions and so on. I do not know whether the Minister has in mind to establish such a comprehensive committee or whether he is confining his thinking at the moment to a committee which would be restricted to considering the structure of the health boards. My impression is that in so far as the Minister has a committee in mind it is a very restricted concept of a committee dealing with the very narrow field of the administrative structure of the health boards. What the president of the Irish Medical Association had in mind was a committee which would be given a much wider and more fundamental task than simply looking at the health boards. While an all-party committee could undoubtedly get to work in looking at the long-term situation, there are certain other areas which confront us and certain matters which call for immediate decision. We cannot wait for the establishment of such a committee to deal with a wide number of matters.

For instance, there is the general question of eligibility. Allied to the question of adopting this Estimate, the Minister has put forward a proposal to increase the income limit for limited eligibility services. His proposal is to increase the existing figure to £3,000. As he said, this is a tangled sort of situation. It is not a situation about which one can have a clear cut view. The Minister is acting, perhaps, typically, but foolishly in deciding on this change unilaterally. I understand that he has not secured the goodwill or the agreement of any of the bodies concerned in regard to this extension. One reason why it is difficult to express a definite view on the proposal is the lack of certain information. There are conflicting opinions about what is involved. The Minister says that the change is only maintaining the status quo, that about 85,000 people are affected and the suggestion is that if this change is not made people eligible now for these services will become ineligible during the next 12 months. On the other hand, the medical profession say that as many as 300,000 people are involved. None of us could contemplate any proposal which would result in putting an extra 300,000 people on to the already overstrained hospital services.

I should like to know who is right in this matter. If it is a question simply of retaining eligibility for people who are eligible, we support fully the Minister's proposal but if there is a question of a substantial increase in the number of persons to become eligible for these services, we would have grave doubt. There is no question of our not wishing these people to be eligible for the services but it is our contention that because of the way in which the hospital services are organised at present, they cannot cope with any major extension. Would it not be possible for the Minister and his Department to come together with the medical profession and anybody else who might be useful in this context for the purpose of working out an agreement as to what exactly is involved in the proposal? Then, we would all know the position and would be enabled to give a positive view on the Minister's proposal.

In the absence of definite information regarding the situation, we have no option but to accept the Minister's view that, by and large, the proposal will result merely in retaining in eligibility those who are entitled already to the services. It is in a doubtful way that we support the proposal since we are not sure of what is involved. I do not know whether this is the sort of matter that could be dealt with by an informal committee of the House working with, perhaps, people from outside but it is a sort of situation in which the type of co-operation of which I have been speaking could be afforded by us to the Minister to help him ascertain where the best solution lies. The ideal course is to endeavour to ascertain what is the maximum number of the population with which our hospital services can cope and then to make services available to that section but we have only the vaguest idea as to where that line can be drawn.

I was very disappointed with the Minister's reference to private hospitals and nursing homes. I have said repeatedly that I support fully the continued existence of these institutions because I am convinced that they provide a means, if only in a relatively small way, of easing the burden on the public service and on the national Exchequer. To that extent the ultimate benefit is gained by the poorer sections in that some contribution is made towards easing the overall cost of the health services especially in relation to the provision of resources and facilities which would not be available otherwise.

Instead of the Government putting more difficulties in the way of these institutions, they should encourage them to flourish and develop. No government can afford to spurn relief from any quarter in the area of health administration. Neither have any government the right to deprive any citizen of his right to seek and pay for medical care outside a State service, should he so wish. In dealing with this question in a very neutral sort of way the Minister said and I quote:

Nevertheless, I think we can all recognise that the private hospitals and nursing homes have an important part to play in supplementing the public system. It will be my aim that they will continue to receive reasonable subventions towards the cost of treatment of persons eligible under the Health Acts.

I suggest that a great deal more than that is required. The organisations and individuals who run these private hospitals and nursing homes are of the opinion that they are not wanted, that they are discriminated against. Apart from any financial consideration, I suggest that a new atmosphere be created between the Department and these institutions.

On many occasions I have made it clear that we support fully the continuance and the extension of the Voluntary Health Insurance service. This body have been one of the most successful innovations in the whole field of public administration. They make a very positive contribution to the welfare of a very large section of the population. I would hope the board would be encouraged constantly to develop and extend their services and that the principle of voluntary health insurance would be fully subscribed to by everybody concerned.

I think it will be agreed that one of the most important recent developments has been the publication by the Irish Medical Association of their discussion document. This is a very useful contribution to the whole debate on the development of health policies. In that discussion document, a working party of the IMA discussed the feasibility of a compulsory specialist and hospital insurance scheme as an alternative to the present system.

Accepting, first of all, that it is only a discussion document, I regard it as worthy of the most serious consideration. The IMA are to be commended on the very valuable initiative they have taken in this regard. The first thing to be said about the document and the concept is that it is very definitely relevant to the whole Irish situation. At the same time, it is supported by the practicality which we can observe of similar schemes operating at present in countries as far apart as Canada and Belgium.

It is also interesting to note that, where they wished to go outside this country for precedents or to examine other systems, they went mainly to the original six founder members of the EEC where they could find this sort of concept operating reasonably successfully. I believe the discussion will be very important and very useful and, at this stage, I would like to indicate support in principle for a State supported compulsory insurance scheme of the sort the Irish Medical Association are discussing.

On this side of the House we place in a foremost position in our thinking on health matters, and in our plans for the future, a general extension of the general medical services. By that I mean a controlled and planned extension with the rate of extension related to the overall improvement and advancement of the existing services. I particularly want to emphasise here again that this is not an area in which there should or could be any dramatic extensions without making the appropriate arrangements to cope with those extensions. If you extend the service in a haphazard and unplanned manner, without making the necessary financial and administrative provisions to cope with that extension, you are diluting the service and making it less useful, less important, and less beneficial to those already in receipt of it.

There should be general agreement on the whole concept of a planned, orderly, controlled extension of the general medical services as we have the resources to do that. Perhaps that could be put forward and agreed upon by us all as one of the basic things to be incorporated in future planning. If we have the sort of all-party committee which is being talked about, I would hope that would be quickly agreed upon and that sort of extension of the general medical services would have top priority and would be a main plank in the future development of the health services.

Everybody shares the same concern about the escalating cost of the general medical services and the choice of doctor scheme. A great deal of care and attention will have to be given to it. If, in the community interest, this service needs to be extended slowly and carefully to cover a greater section of the community, it is essential that we should make sure it is as economic, as well run, and as carefully administered as possible. One factor is the ever-increasing cost of the drugs bill in the general medical services. The pattern of drug usage and drug prescription in the general medical services is of very great importance indeed. We will all have to study very carefully the report of the working party which has just come out on the rising costs of medicine and the pattern of prescribing.

A very interesting statistic which has emerged from that report is the fact that 65 per cent of the total cost of the choice of doctor scheme results from the supply of medicines and the supply of appliances. That is a fascinating figure. It deals a very serious blow to the concept of very well paid doctors being responsible in the main for the escalating costs of the general medical services. An impression has been created—and I am afraid our Minister for Finance has been most malicious and unhelpful in this connection—that highly salaried doctors are so operating this service and getting so much out of it that it is ruining the whole country. This report, as I say, brings us up short on that aspect and shows that 65 per cent of the cost comes from medicines and appliances. We have to see what can be done to improve the situation.

Another interesting factor is the prescribing patterns between this State and the Six Counties. Perhaps the immediate implication is that it is because of the charge for prescriptions in the Six Counties that we have the difference. If that is so, then that situation will have to be seriously and carefully considered. But it is interesting that there is this difference between the prescribing patterns in the two different Administrations. This very high cost of medicines demands that we do as much as possible to rectify the situation. I do not know whether there is a possibility of the establishment of a central purchasing agency for all of the medicines required by the whole health service. That might be feasible and, perhaps, lead to very considerable economies. As I understand the situation at present in regard to the purchase of medicines, drugs and appliances, it is very haphazard. It may be the best system in all the circumstances but, in view of the disclosure of this 65 per cent figure in the report, every possible innovation of that type should be considered.

I come back to the question of the future; what we are trying to deal with at present is a situation which has two aspects. First of all, in common with most other Community countries, we have a situation where the cost of our health services has been rising steadily and, to some extent, seemed to be rising uncontrollably. There is an important difference to be noted there. It is one thing to have the cost of a Government service rising steadily and inexorably if that rise is subject to some type of control. But if there is a service, such as the health service, the cost of which is accelerating from year to year, apparently out of control, then that is something that has to be examined very seriously by any community. That situation has been evolving here over a long number of years. On top of that, in this year, we had the sudden realisation by the Government of the mess they have made of our finances and a panic attempt to deal with the situation, to try to get public expenditure and the budgetary situation under control. Had there never been that ghastly mismanagement by the Government, I think we would all agree that there would still be a need to examine the long-term implications and possibilities of our health service. But, because we have had this crisis, panic sort of situation, the need for that examination is all the more urgent.

What can we do about that situation? How can we attempt to see to it that, in so far as possible, our health services develop logically, systematically and at a cost within the capacity of this community to pay? As a community, I do not think we mind making sacrifices if the community purpose is worth while and desirable. I think the idea of the community making fairly considerable sacrifices in order to provide itself with a first-class health service would be generally acceptable to the electorate. But I do not think anybody wishes to accept a situation where the costs keep escalating and the benefits and quality do not rise correspondingly. That is the sort of situation we have to face. How can we seek to bring about a situation where the best possible service, covering the greatest possible number of people, evolves at a cost within the capacity limits of the community to pay?

It is clear that, in our consideration of that situation, there are two major areas of approach. The first is preventive medicine and the second is community care medicine. Recently I began to come to the opinion that there is probably a third area of approach which is, perhaps, subsidiary to the other two but related to them, that is, something to be done inside our hospitals. The Minister referred to this. It is very encouraging to learn that the Medico-Socio Research Board are carrying out this inquiry because, from what one reads of what is happening in other countries, there is, perhaps, a possibility of some important developments inside the hospitals from the point of view of more economic administration. In different countries now, in regard to in-patients, there are new procedures being adopted and tried out. It is very important that we keep abreast of these developments and this research. It is very encouraging, indeed, that the Medico-Socio Research Board is engaging in this area because it is one where the other two main lines of attack I mentioned—preventive medicine and community care—could be supplemented. In this whole area of the administration of our health services it is the negation of intelligence and common sense not to be making major efforts in regard to preventive medicine. Surely this is an area where, in the long term, a very significant contribution could be made towards keeping the cost of the health of our people within the capacity of our community to pay. I am more and more convinced that this can and should be a very rewarding field not only from the point of view of the happiness and welfare of our people but also from the point of view of the long-term development planning of our health service in regard to cost. There is no money immediately, I think, in preventive medicine. Certainly, it is not facing up to realities if we do not devote far more attention, energy and finance to preventive medicine.

Certainly that is true in regard to alcohol, which is, perhaps, regarded by many—and I do not think I disagree with the view—as one of our most serious social problems, as well as drugs, tobacco, lack of sex education. There is the question of physical education and there is the question of mental health. There is the question of diet. All these areas are to a greater or lesser extent sadly neglected and have been sadly neglected by all of us, by Ministers for Health in the past and by the present Minister.

I asked some questions here about dieticians. There are those who argue that a proper diet is of fundamental importance but it is almost totally neglected in our hospitals and institutions. The number of qualified dieticians employed is absurdly small. I believe that if we were to have massive comprehensive programmes of education in regard to alcohol, drugs, tobacco and sex that could make a very significant long-term contribution.

I do not know if the Minister has anything in particular in mind with regard to physical fitness. This is an area where something profitable could be done. We are by nature and tradition an outdoor people, active in games and sports generally but, in so far as the great body of the public are concerned, physical fitness does not get the recognition it deserves. Even in our schools games are played very much as a routine matter. There is scope, perhaps, again through the workings of an all-party committee of the House, for a major initiative in the field of physical fitness. As I get older, I become more and more convinced of the truth of the old maxim mens sana in corpore sano. I believe that a reasonable level of physical fitness is essential to any form of intellectual performance. These are areas to which we should, even in present difficult financial circumstances, give increasing attention. In the short term there will be no saving and no great financial benefit but in the long term programmes in these areas would be beneficial in every way. The Minister will, of course, point to the efforts he is making and these are undoubtedly to be commended but there is far more involved than just a programme of health education. A comprehensive approach is needed in these different areas.

The other main area in which the problem of the long-term escalation of costs can be tackled is in the provision of community care. To an increasing extent we must try to take medicine out into the community. This is related directly to an expansion of the general medical service. One of the greatest tragedies of the present financial dilemma into which this Government have walked themselves is the serious disruption in the development of community care programmes. I would hope that when a reasonable level of finance can be made available again to health boards, community medicine and community care will receive increasing allocations. Recent reports and statistics show that we have a peculiar situation in regard to hospitalisation and in the long term we must aim more and more at reducing the almost total reliance we have on the hospital structure and instead provide community medicine and comprehensive community care.

It is important to avail of this opportunity to mention a very serious problem which has arisen in the suburban areas around Dublin and throughout the country. I refer to the availability of the general medical practitioner to the public. This is something fundamental to our whole health services structure. A very high percentage—it may be as high as 80 per cent—of the general public never go beyond the general medical practitioner. The importance of the family doctor cannot be over-emphasised. I suppose there is nothing which contributes more to the happiness and wellbeing of a community than to have a general medical practitioner readily available. Unfortunately, the situation in this regard has deteriorated and is, indeed, totally unsatisfactory. There are reasonable demands by the individual medical practitioner to some sort of tolerable way of life and that means he cannot be available 24 hours of the day seven days a week.

This creates a problem if there is no doctor available at night time and weekends and it is causing a great deal of unease, anger and frustration throughout suburban communities. The difficulty arises because the situation has been allowed to develop haphazardly on its own. I understand there are three main phone call services available in Dublin and I think it is generally agreed that the system is very unsatisfactory, indeed, and the way in which the general public receive attention in these off hours leaves a great deal to be desired. Possibly the biggest flaw arises from the fact that very often it is a young doctor who attends, a young doctor who has no knowledge whatever of the family, its circumstances and, most important of all, no knowledge of the patient. He comes in answer to a telephone call and he is never seen again. The system is unsatisfactory and very serious and careful attention will have to be given to this because the general public must not be left uncertain of what medical practitioner will be available to them at night time and over weekends. The main recommendation of the McCormack report in this area was that this situation can only be dealt with by the evolution of group practice. I would like Members who have more detailed information on the situation than I have to discuss this aspect.

It seems at first sight that group practice would provide part of the answer. If that is so how can we go about having more and more group practices established? We must recognise that the present situation is unsatisfactory and that we will really have to do something about it. It involves some sort of system whereby unfortunate people who need urgent medical attention at times when their family doctor is not available will be able to have some satisfactory way of procuring that attention.

I mentioned a suggestion that the Department of Posts and Telegraphs would look into the question of seeing if they could provide services by telephone the same as they provide for weather and time. I believe it is suggested that a telephone number would be available in Dublin which people could ring to know which hospital is doing accident duty. Perhaps that suggestion could be considered.

I want to repeat that on these Opposition benches we regard the present situation in relation to the administration and financing of our health services as a very serious, urgent national matter. While we feel it our duty to be critical and to point out the inadequacies we do not want simply to stop at that. We want, as far as we can, to make a positive contribution to the situation whether it is by taking part in a debate or in some more positive form in committees, informal or formal. We have on these benches a very considerable volume of experience, knowledge and expertise. We have Deputies who serve on health boards and committees throughout the country. They are in close touch with their consituents and know what their needs are. They have invaluable experience of the operation and administration of the different agencies, boards and institutions. We want to ensure that this experience which we have at our disposal is used in some beneficial way to help in the present critical situation. We would like, even in Opposition, to be able to make a contribution towards the long-term planning of the health services and towards coming to grips with the very fundamental problems which are there in the long term. If the Minister has any proposals whereby the experience of all the Members of the House can be mobilised and brought to bear on those problems we will certainly look very favourably indeed on any such proposals put forward by him.

I want to reiterate what I said in my opening remarks that this is a very unfortunate year from the point of view of our health services. It is irrefutable that the amount of money the Minister is providing in this Estimate is not enough. He would be performing a real national service and discharging a very solemn obligation, which is placed on him as Minister for Health, if he recognised that fact now, faced up to it and persuaded his Government colleagues that sooner or later additional moneys will have to be provided this year for our hospitals and health boards and the sooner it is done the better. Whatever else has to be changed, whatever budgetary dispositions have to be altered, whatever devices have to be resorted to a considerable sum must be added to this Estimate, which the Minister is asking us to accept, if the general public are to receive the level of medical care and attention throughout this year to which they are entitled.

It is appropriate that I should pay tribute to Deputy Haughey for what was a very good contribution to the debate. I hope the Minister will be persuaded to favourably consider what Deputy Haughey said in relation to the participation of members of the Opposition in an all-party committee to examine our health services in general. We have come to realise in recent times that health and the health services in general should be discussed more, costing as they do such a high percentage of our gross national product. There is a growing awareness of the health needs of the community and their cost.

Perhaps one of the annoying aspects of the whole matter is that we have had a succession of Ministers for Health, each of whom set out, on assuming office, to outbid his predecessor in the prorities he established. It seems to me that each Minister for Health who has assumed office during my time at any rate set out to make his mark on the Department of Health. That may be admirable but it had the effect of relegating to a position of unimportance the set of priorities previously established. The net result of all this probably has been extravagance, waste and the abandonment of programmes which were considered previously.

When the late Mr. Childers was Minister for Health he abandoned the Fitzgerald Report on which a great deal of work was done by the previous Minister, Deputy Seán Flanagan. The position has gone on like that. The result is that our health services have suffered because we do not know, if I may be so bold as to call it the Corish Plan, will ever be implemented. We may find a new Minister for Health coming in abandoning that and deciding that he has other ideas on it. We may find our hospital services back to square one, which could be disastrous. I wonder what we as a Legislature can do about setting out a system of priorities for our health services so that a plan for our hospitals and for the health services in general can be a continuous ongoing one without fear of interruption or abandonment by anyone who may assume office as Minister for Health. I am very disposed to the idea that we might as a Legislature consider an all-party committee to examine this and decide on a system of priorities that will be abided by in the future. This might enable proper progress to be made in our health services. I put this point to the Minister because I think he is in a unique position to change the procedure that has operated up to now. He may see to it that what he thinks is the most important aspect of the health services and the plan he has proposed and on which he has spent so much time will be brought to fruition and will be operating long after he has gone and being implemented as he sees it. This is very important.

The statement by the Minister about the audited accounts of health boards being so much in arrears would be another justification for having an all-party committee examine the structure and functions and make a cost-benefit analysis of these boards. The fact that they are so late in presenting their reports is an indictment of the effectiveness of these boards. I am perhaps a little dismayed that the Minister has not come out categorically in favour of the all-party committee. He posed some options in concluding a speech some weeks ago when he said that the review team could be comprised of a special departmental team with outside consultants. Personally, I would not consider such a team with outside consultants as being capable of doing this job because of the fact that there would be no public accountability and we would not know what was happening. Nor could I consider having a team of outside consultants acting on their own, because many Deputies will agree that we had these teams of outside consultants deciding to plan our services for us without our having any say in it. I would be opposed to that.

The Minister then talks about the all-party committee of the Dáil or a body representative of all parties or representatives of the professions within the services, the administration of the Department of Health. I originally spoke about an all-party committee and the Minister has posed the other possibilities. The Minister asked us to discuss this and I feel it may be pertinent to discuss it now. In talking of open Government and involving the public it might be a very good idea to include on this committee members of the profession and the consumers. Perhaps its terms of reference might be extended so that they would not necessarily confine themselves to examining the health board structure but would include other priorities in the health services. I hope the Minister will soon announce his decision to agree to such a committee being established even if it is a plain, all-party committee of the Dáil. I am very much in favour of having the Opposition brought in on this. This is how this Parliament should operate. We are talking about health services. We have all shown concern for them and I would hope that party politics would not enter into this and that we would involve the Opposition in this very important exercise. I hope our thinking will be broad enough to involve Members of the Opposition who have the experience, the expertise and the interest in considering this service.

We had a peculiar experience since we came into Government. I may be wrong in this but I think that for the first two years health got very little time for discussion in the House. I wondered if we had abandoned the idea of having health Estimates. Then we had a good deal of time given to health in the past year, perhaps more than to any other Department. It seems only a few weeks ago since we were discussing health in general. The Minister's speech was a very fine, wideranging speech and very informative, but to repeat many things I have said before would, perhaps, be unnecessary. However, there are some aspects of the speech to which I should refer. I should like the Minister to consider seriously the whole position before he makes a decision on the question of drug eligibility. It is not merely a matter of dealing with the hardship cases and saying that due to inflation we must bring the figure up from £4 a month to anything over £10 a month. There is considerable hardship which is not related purely to the cost of living and the consumer price index. There are hidden factors in our cost of living and to base it solely on the CPI might not be correct. Would the Minister again consider the situation before he decides to deprive so many people of treatment? Perhaps he would think of some compromise because I fear the decision he says he will take could mean considerable hardship for a number who are now dependent on the subsidised drugs scheme.

I recognise that there is a problem as regards hospitalisation eligibility as outlined to the Minister by the Irish Congress of Trade Unions. I recognise the difficulties about self-employed people, small huckster-shop people for whom there was a £600 limit at one time, and who have a very difficult problem in trying to manage at present. I also recognise that there are teachers, clerical workers and others who would be deprived and some action must be taken by the Minister to see that those people do not suffer very serious hardship. I only recognise this within the context of the overall policy on hospitalisation and this is where I return to when the Minister first announced his intention in August, 1973, to introduce a free hospitalisation scheme, I have been critical of the Minister in this regard but I feel justified. It was an ill-advised move because it was made without consultation with interested parties. I have said this over and over again.

It is no reflection on the Minister that he sought to introduce the scheme because of the glaring inequities and anomalies that exist. You find people with £2,000 a year income who have no free hospitalisation and others with £5,000, £6,000 or £7,000 a year income with free hospitalisation. Of course there are glaring inequities and anomalies in this scheme. On face value, what the Minister was attempting to do was to rectify these and he was fully justified in thinking along those lines. Before you do anything like this you must ensure that our hospital system is geared to take the extra numbers. Everything that goes on in society is a matter of consultation. It is a sine qua non for any decision that is taken by Government. You must have consultation with all the interested parties. You can win the support of people and get them to co-operate if you consult with them. This is where we may have made a mistake.

Secondly, it was done without regard to the method of payment to those operating the system. At present, people may not be aware that there are two means of paying hospital consultants. They are paid under the pools system for public patients, and for private patients they are paid directly by the patients or by the VHI. The pools system is the most iniquitous and abominable system known. I always remember referring a patient to a consultant for an operation. He decided he would not do the operation, which was an elective operation, because there were other pressing operations to be done. I phoned him in anger because the child's mother was upset and said, "Aren't you well paid for it?" This was in 1964 or 1965. He said, "Yes, I am paid 1s. 6d. for it." I was dumbfounded because I did not know this. I then made inquires and found that they are paid very small sums under the pools system, such as 40p for a tonsil operation and £2.50 for a major heart operation. This is how the system operates and Deputy Flanagan would know this very well.

Consultants were prepared to tolerate the system because they were being paid very well under VHI by their private patients. But this did not detract from the fact that it was an iniquitous system. When the Minister decided to have free hospitalisation, the consultants said that they would not tolerate the pools system. I have no hesitation in indicting the Department because in their consultations with the doctors—and I hold no brief for the doctors—they never once put forward a proposal of the form of payment they were going to make to them. When the "negotiations" broke down, they did so because there was nothing forthcoming from the Department. One compromise to which I objected very strongly was that the VHI system be made available by the Government to 15 per cent of the population. I would be opposed to that because this would be discriminating against the lower income group. That idea was abandoned. The next compromise was the setting up of a review body in August, 1974. Maybe I am too impatient and impetuous, but I cannot see why a review body is sitting since August, 1974. By the way, it is like a Gestapo office. You could not get any information out of it. It is like a top-secret nuclear station. When I asked whether they were making any progress I was told, "I am sworn to secrecy."

They must be afraid of the Deputy.

Maybe they are. It took a lot of time and a number of parliamentary questions to get any information about what they were doing. I thought we might consider whether they were suffering from bedsores because they were sitting so long. All the information they could possibly require should have been got in six months. They were to examine the methods of payment to consultants in hospital schemes in various countries. Someone said they went to Scotland, but a uniform system of payment operates in Britain, so why go to Scotland? I could not see any logic in that. I was then told they were going to Canada, but I do know that the Department had full details of the Canadian system in January, 1974, because a member of the Department of Health went to Canada in December, 1973. I am wondering what the whole purpose of this is. Is it a stalling operation? Is it to leave them sitting there ad infinitim until we forget about it? Believe me, I will not forget about it. I will pursue them relentlessly until we find out what they are producing and what the purpose of it is. I should like to see a review body such as that—and there are very distinguished members on it—knowing what they are trying to seek.

I should like to see a body examining the methods of financing our hospital system and alternative methods of financing our health service. This is what we should be looking at. An astonishing thing is that the Irish Medical Association have taken the initiative from the Government by setting up a working party to examine alternative methods of financing the health services, both the hospital service and the general medical service. This is a great tribute to them. It has, of course, cast terrible aspersions on the Department of Health that they are not engaging in such examinations. I wonder should we not be examining how we might have a voluntary health insurance scheme. I must confess I was critical of the VHI in the early days before I realised how it operated. It is the most efficient organisation in this country. It operates well and provides a good service. If we had such a body operating a general hospital service for this country with all persons eligible for membership of the VHI under the proposed Government subsidised scheme, we would have a very good hospital service. That would be most acceptable to the public and those operating it. I hope that such a scheme will be at least examined by the Department.

The public are very happy with the general medical services scheme. Great tribute must be paid to the late Donagh O'Malley for his courage in moving in that direction. I have the greatest admiration for him because he was a man of action, not words. The work started by him and carried on by his colleague, Deputy Flanagan, was tremendous. It was consultation all the time, but what was achieved made it all worth while.

The amount spent on drugs is phenomenal. This is a source of concern. Perhaps the Minister might look at this problem again. When talking about drugs what should we look at? Is the doctor aware of the cost of the drugs he is prescribing? Is the patient aware of the cost of the drugs being prescribed for him? If the amount of money spent on drugs were reduced perhaps other priorities in the health services could be met. Our strained financial resources must be utilised to the greatest possible advantage.

Would it be possible for the Minister and his Department to examine the Swedish system where essential drugs are free? If drugs are not essential, the patient might make a contribution. This could help meet the problem. There could be three different categories of drugs: those which would be free, those which would be subsidised and those which would not be subsidised. There is no question of saying to the patient that he is being deprived of anything because if a certain drug is not vital to him, or may be considered of questionable value, we should ask ourselves if he should have the luxury of that drug at the expense of someone who needs an essential drug. This is the way we should look at this problem. I would like to see an investigation into the feasibility of having such a scheme in operation here.

The question of whether a person receiving a prescription should pay an initial amount frightens politicians, first, because of the unpopularity of such a move and, second, because those most in need might not have the necessary money to pay for the prescription. The advantage of such a scheme is that it is a deterrent to abusers. We must weigh up which is the most important. It is a difficult decision to make. Whether the administrative costs would warrant the operation of such a scheme is another matter we would have to examine.

It is interesting to realise that the more socialist the country the more they have applied this system. I completed a book a while ago on the Soviet health services and they apply a prescription fee. There is also a prescription fee in Rumania. The amount collected under such a system may not be very much but the amount saved would be enormous. Certain people will call a doctor for trivial reasons. They always link a consultation with a prescription. If patients say to themselves that if they call a doctor they will have to pay for a prescription, that could act as a deterrent and that would achieve our purpose. This is something we will have to look into. We should not make political capital out of it. To say such and such a Government did this or that would be wrong. We should consider what is best for the country and for the service in general and ensure that the money saved could be diverted to very urgent uses in the service.

It is tragic that there are so many cases in need of hip replacements who are completely invalided because they cannot obtain this tremendous service. It is most regrettable that there are only one or two men in Dublin giving this service. The man almost exclusively working on this has a waiting list of two or three years. I know of a man who had one hip done, and two years ago they promised to do his other hip six months later. What a pity he has not had his second operation. These people could be restored to active life and back at work. The saving to the State would be tremendous. The man I mentioned is receiving social welfare benefit.

As I said, if we could deploy our money into a good service which would help get people back into the community, that would be great. It is tragic that such a revolutionary advance in medicine and surgical procedures cannot be availed of by many more people who need it. The results are miraculous because after such an operation a patient can literally run around. I am not asking for extra money for the service. I am asking if we could divert funds to an area where they are badly needed.

I have often wondered if there is a committee in the Department of Health who consider applications. I always know the Department of Health would consider applications but I wondered who considered such applications from hospitals for such a facility. Did a committee decide? Did they have regard to other priorities? How did they establish their priorities? Did they work on the principle: "I know him, he is a good pal"? So far the Department of Health have been rather remote. Would the Minister examine this aspect to see what could be done?

I was very pleased to read in the Minister's speech about days spent in hospital. I am glad there is a realisation of the need to examine this. I have said that over and over again. Because patients are detained too long beds are not available. Under this pooled system there is an incentive to keep patients in hospital. That position must be examined urgently. We might look at it seriously with a view to helping the situation. I hope the Department of Health will give a directive to the health board about giving a well-written, easily read leaflet to patients urging them not to abuse the health services and not to call unnecessarily on doctors. We realise that we cannot deter them completely because some might leave a serious illness unattended if they were to go too religiously by the directive. There are some useful over-the-counter medicines and we must not confine them too strictly to prescriptions. A number of these have, believe it or not, reduced considerably the demand on the health services. The Minister and his advisers should take that into account. We must not be misled into thinking that we can control everything. An examination is needed into those that are worthless, but I have reason to believe that there are a number of worth-while preparations. A little education in this field could help.

I am wondering has the Minister looked at the question of extending the medical card scheme. One of the reasons that I opposed the hospitalisation scheme was that I thought again the money might be diverted into this area. The IMA have set up a working party to see how the medical card scheme could be applied to all. This was a tremendous move, and it could possibly be done, but I would like the Minister's Department to examine this to see if it could be done. The Minister may say that for every £1 it costs £1 million, but it does not cost that. Number one, any thought given to it should be in consultation; number two, the scheme bringing in the middle and upper income groups would not necessarily mean the same items of service in a year for a person.

That brings me back to a point raised by Deputy Haughey. The comparison made between the drug situation here and in Northern Ireland is not quite valid, because in Northern Ireland everyone is on the health service, and the upper income group do not make the same demands on the doctor and on drugs as the lower income group. We are confined to the lower income group who make the most demands on the doctors' services. Therefore it is not a valid comparison. When the former Minister for Health, Mr. Childers, was talking about the number of visits per year per patient he was making a false comparison in saying that in England it is such-and-such. In England they cover the entire community. I pointed this out over and over again to him, and I was right.

In talking about introducing anything into the health service we are thinking in terms of what it will save. Therefore the vaccination scheme is very important. Perhaps in an emotive atmosphere people have turned away from the three-in-one. This involves a process of education and talks to the community so as to make people realise that the fears that were raised were unfounded. Furthermore, vaccination is not just a matter of putting in a needle. Full details of the patient's history, allergies and so on should be available to the doctor. More selectivity and less indiscrimiate vaccination is desirable. I would also like the Minister to consider a measles vaccination programme. There would be an enormous saving in bed days, in the number of children in hospital, and also in the cost to the health services of this infection. While I am trying to introduce extra expense on the health services, the overall result would be a saving. If the Minister's Department would examine the results in Britain in this area of preventive medicine, I think he would be convinced that it would be a worth-while project to undertake.

In regard to the health boards, a number of hospitals have expressed great concern at the fact that their budgets will run out in September or October. Some of the biggest teaching hospitals in Dublin are alarmed at this. If there is this cause for alarm— and these statements have no doubt been made by the hospitals, having examined the matter in great detail, in the knowledge that their budgets will not stretch until December— there is an onus on us here to do something before an emergency arises. We should not make a final decision that there would be no more money forthcoming. There may have to be an emergency budget. There should be discussions with these hospitals. It should be obvious by now whether they will be able to live within their budgets. We should have a statement as to whether sufficient money will be available to the hospitals. It would be a disastrous situation if we had to close hospital beds when there could be a demand on them coming into the winter months. That is something we should know about now.

Another thorny question I raise is whether the Department will accept responsibility for family planning methods. The Department of Health are paying the cost of certain types of family planning methods, oral contraceptives. The argument that oral contraceptives are cycle regulators does not stand up. To give the late Mr. Childers his due, he had no hesitation in stating definitely the number of prescriptions for the pill per se as an oral contraceptive. The percentage of cases in which it would be prescribed as a cycle regulator would be, to my mind, less than one per cent. Therefore the Government and the Department of Health are accepting that they will pay towards the cost of a certain type of family planning, but of course that is restricting family planning to a certain category, those for whom oral contraceptives are not indicated, but when there is a risk involved and the doctor knows that, the doctor also knows the alternatives. The Department are equivocating on this. It is not a question of seeking legal advice but of deciding if you approve it one way you approve it all the way. We have to be bold and courageous and say we are doing it or not. I think we should say it because it is an area where we must have frankness and honesty. There are families who want help and we are denying them. If a debate on this took place it would be useful, but the Department must not equivocate. We have no time for this. We will have no equivocation on it. We must be bold and determined about it. Hiding behind this subterfuge of the pill as a cycle regulator is regrettable. It is an easy way out. We can hold up our hands and say: “We know nothing about it”, but that is dishonest.

We have to look at this question of the Medical Registration Council who decide standards which doctors must uphold if they are to continue on the register. It calls for discussion with the public. It is again regrettable that the public were not consulted on this and are not being consulted on it at the moment. There are areas in which people may be dissatisfied with doctors. They do not know how they can express this dissatisfaction. The Medical Registration Council are hamstrung; their powers are not sufficient. They are archaic in their methods and operation. Even the disciplinary procedure is archaic and needs updating and broadening.

I hope a lot of consideration will be given to consumer participation on this council. The consumers are the very people in receipt of medical care and who matter, and also of course there are the taxpayers. So I hope we will have more of those on this council and that the Department before they come out with this could have discussions or perhaps a draft plan of what they have in mind. This should be made available so that before it goes in to the form of a Bill it might go for discussion. This is very important because, unfortunately, narrow interests only see these things and they never go beyond those. Therefore we have legislation passed here which people are unaware of until it is finished.

A question also which the Minister will have to consider is the number of doctors. This can be bypassed by saying: "This is a matter for the Department of Education." We cannot look at it that way. We have to decide how many doctors we need in the country, whether we can have so many junior doctors in our hospitals if there is no hope of a career structure for them. We may have too many at registrar level and they may find they will never progress beyond that because of the too few vacancies at consultant level. We have to decide the number we are going to admit to our medical schools and the criteria we are going to apply. These are plans which we should be formulating now because conceivably we may end up by having a shortage of them and, as the president of the IMA said, if we had more doctors in the hospitals we might get a much better service at lower cost. He mentioned, and this is interesting, that despite what people think, only 10 per cent of the personnel in the health services are doctors. That is one of the most astonishing things. When people think of the health service they identify it with doctors, but they form only 10 per cent. So one can imagine the vast administrative structure in the health services.

The question of nurses arises in hospitals, the work they perform and whether there is a proper career structure for them. As the Minister knows too well, we have had so many applicants for positions in nursing schools. Have we decided on the number of nurses we require? What do we propose doing about them? Is the present system of recruiting archaic? Nearly three years ago I asked the Minister to examine this because there is no Deputy in this House, especially the rural Deputies, but has requests from constituents for placement in a nursing school and there is this perennial problem of writing to different nursing schools. The Minister has said nothing about this, and it is a serious and a growing problem. It is a frustrating one for potential nurses, the young girls who have to write to so many hospitals seeking admission.

My proposal is very simple. All I ask is that An Bord Altranais, the Nursing Board, might set up a general interview body representing matrons of different hospitals. An applicant would apply to them and would indicate her preference; they would interview her and decide as a result of that to assign her to a certain hospital. It is a simple thing, but look at the convenience to these poor applicants, these girls who write to so many hospitals. It does not pose any insuperable problem to set up such a body. The Minister offered to investigate it, but he has never come back with a reply on it or some explanation as to what was wrong or why it was not proceeded with. It was 1973 that I first brought it to his attention. It was only as a result of a number of rural Deputies asking me how to get constitutents of theirs into hospitals.

In order to help the Deputy to make the best use of the remaining time I should like to inform him that he has approximately eight minutes left.

I should like to go again into this question of getting beds for patients. It is a big problem and worry, especially for elderly patients. I wonder if the Minister has examined this aspect of it or even that of getting appointments for out-patients in hospitals. I still feel that there are not enough consultants employed.

With regard to eye examinations, I wonder what progress the Minister has made. There is nothing in his farranging speech about whether he has come up with any proposal regarding those eligible patients who have appointments for eye examinations. It was proposed that ophthalmic opticians might undertake this work, but nothing has been done about it. I might bring the Minister's attention to the fact that a precedent was created for this with the Department of Social Welfare. The problem is growing greater and something should be done about it.

This matter to which Deputy Haughey referred about doctors' time off and the non-availability of doctors at weekends and night is a growing problem of serious concern to the public. The death of the child due to the fact that a doctor was unavailable is something which caused considerable disquiet and sympathy among the public in general. In view of the demand by the public for some system that would prevent a recurrence of this I propose a very simple system— perhaps it is only I who think that any suggestion I make is simple although it may pose insuperable administrative problems and headaches for the Department of Health. However, a scheme could be introduced to cover this matter. I suggest that one hospital take on the task, making use of the doctors employed in that hospital. There are many junior doctors in the hospitals who could easily undertake this job. If a local doctor was not available within a reasonable time, a person could ring a central number at a hospital and explain the problem to a doctor. That doctor, after listening to the details of the case, could decide if it was an emergency or not and, in the even of his failing to locate the family doctor for an emergency, could arrange for an ambulance to collect the patient concerned. I have a motion in relation to this matter tabled for discussion at a meeting of the Eastern Health Board but the problem will arise in the other major cities such as Cork and Galway. Even if we could save only one life by introducing such a system it would be worth while. I do not think there would be much expense involved because of the number of doctors in hospitals.

Deputy Haughey suggested the group practice system as the answer to this problem. I accept that that is the real answer but if we are to have that we should have incentives for doctors to combine in group practice so that they can give a 24-hour service without anybody being overburdened. The Department should seriously consider giving them more incentives in this regard. We must also ask if our casualty departments are being overburdened and inundated with calls and attendances by people who are not casualties. This should be looked at because it could be imposing an enormous strain on these departments which are at present unable to cope with what they are getting.

I should now like to deal with the free transport service made available for invalids unable to get to hospitals. In the cut-backs this service was cut back too much with the result that there are cases in need. I was informed of a case yesterday of a man who had a leg amputated. That man is expected to get from Ballyfermot to Dún Laoghaire and he told me that even if he gets there by bus he must walk one and a half miles. He must travel to Dún Laoghaire for treatment but there is nothing available for him. In making the cut-backs it should be realised that there are cases needing attention and they should be looked at. There is also a problem with regard to patients who are invalided after a stroke. I do not think it is right to confine them to the house as vegetables; an attempt should be made to rehabilitate them. This is a very serious problem and people are losing hope sitting at home. There should be more day centres for them and some means within the health board areas of getting facilities to these people.

I do not think it should be our concern as legislators to be looking at this all the time. The Department should make some provision for this. As a public representative, I have seen many cases of people confined to their homes and nothing being done for them. Yesterday I saw a 48-year-old man who is confined to the house. It is grossly unfair that a man of that age should be confined to his home, a vegetable, because there is no way of getting him to a centre. I keep trying but it is very frustrating and sad that I cannot do anything for such people. I ask the Department to look at this matter and discuss it with the various health boards.

The fact that the Minister in his speech, and Deputies Haughey and O'Connell, have discussed examination of structures and methods of financing the health services, in general, shows that there is considerable disquiet about the way the health services are developing. There is considerable worry about the overall cost. Deputy O'Connell is correct in saying that the starting off point for any discussion about the present condition of the health services must be the mid-sixties when the White Paper on the further development of the health services was published. At that time all of us involved approached the questions from an idealistic point of view. We were all determined to get rid of what was bad in the old poor law system, in a system which differentiated socially between people, a system which made paupers by definition out of one section of the community. Nobody can now question the sincerity of all those who took part in the dialogue at that time.

Obviously, there were divergences of opinion as to how the new service should be financed, what structures should be set up to administer it. There was the argument about rates against taxes and the argument about insurance against direct taxation, and other arguments, but they were all based on a fundamental determination by all to set up a new health service. The determination was to set up a service which would not merely get rid of all the objectionable features of the old system but be a model to other countries as to how a modern sophisticated health service should work. The fact that the Minister finds it necessary, in the course of his speech, to question the situation about the structure of the health boards is itself indicative of his own disquiet about the situation. The fact that there seems to be a general agreement in the House about the setting up of a committee representative of all the parties—I do not know who first made this suggestion but, in the course of the only other speech I made on health matters, I put the suggestion forward a few months ago —is another indication of disquiet.

I am pleased that the new president of the Irish-English-Canadian Medical Associations has given it his support, on the basis of a non-party approach. The mere fact that the Irish Medical Association are considering ways and means of financing the health service, that Deputy O'Connell spoke of the value of an expanded VHI system, and that Deputy Haughey, on behalf of Fianna Fáil, approves of the idea of a compulsory insurance system, shows basically that there is not a great deal of difference between the parties inside or outside the House about the need for an examination of two items, cost and financing. I should like to take this opportunity of wishing, as I did in the course of a piece I wrote for the Irish Medical Times but which was omitted, the new president and his wife the best of success in the next 12 months and to say how pleased I am about the appointment of Dr. O'Donnell as president of the Irish-English-Canadian Associations. He is a very brilliant paediatrician. He is also a very likeable and honest man. I cannot let the occasion go by either without paying tribute to his wife whom I recall on one occasion managed to fulfil social functions in spite of having to arrive on crutches. I have no doubt that if she packs it in again and has to arrive on crutches she will charm her way from Dublin via London to Montreal. I wish both of them every success. In the course of his Kilkenny speech at the weekend the new president had things to say about the hospital structure, particularly in the city of Dublin which comes under the Eastern Health Board.

Debate adjourned.
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